Healthcare Provider Details

I. General information

NPI: 1699255190
Provider Name (Legal Business Name): ELLIS HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 MCCLELLAN ST STE 202
SCHENECTADY NY
12304-1020
US

IV. Provider business mailing address

624 MCCLELLAN ST STE 202
SCHENECTADY NY
12304-1020
US

V. Phone/Fax

Practice location:
  • Phone: 518-347-5113
  • Fax:
Mailing address:
  • Phone: 518-347-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number4601001H
License Number StateNY

VIII. Authorized Official

Name: PAUL A MILTON
Title or Position: CEO
Credential:
Phone: 518-243-4175