Healthcare Provider Details

I. General information

NPI: 1649204512
Provider Name (Legal Business Name): KENT ROBERT ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 WOODFIELD RD
MARTINSVILLE NJ
08836-2344
US

IV. Provider business mailing address

1841 WOODFIELD RD
MARTINSVILLE NJ
08836-2344
US

V. Phone/Fax

Practice location:
  • Phone: 732-868-0545
  • Fax:
Mailing address:
  • Phone: 732-868-0545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MA04633700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: