Healthcare Provider Details

I. General information

NPI: 1740412477
Provider Name (Legal Business Name): MICHELLE LYNN ELLERN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
STRATFORD NJ
08084-1500
US

IV. Provider business mailing address

1 MEDICAL CENTER DRIVE UMDNJ-SOM
STRATFORD NJ
08084
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-6708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MB09015700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: