Healthcare Provider Details

I. General information

NPI: 1104424621
Provider Name (Legal Business Name): SCOTT JACOB ELLIS MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 E 72ND ST FL 5
NEW YORK NY
10021-4099
US

IV. Provider business mailing address

PO BOX 12184
HAUPPAUGE NY
11788-0854
US

V. Phone/Fax

Practice location:
  • Phone: 646-797-8305
  • Fax: 646-797-8515
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT JACOB ELLIS
Title or Position: PRESIDENT
Credential: MD
Phone: 646-797-8305