Healthcare Provider Details

I. General information

NPI: 1366428484
Provider Name (Legal Business Name): GEORGE ELLIS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 BOARDMAN-CANFIELD ROAD
BOARDMAN OH
44512
US

IV. Provider business mailing address

910 BOARDMAN-CANFIELD ROAD
BOARDMAN OH
44512
US

V. Phone/Fax

Practice location:
  • Phone: 330-965-0832
  • Fax: 330-965-0155
Mailing address:
  • Phone: 330-965-0832
  • Fax: 330-965-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35060641
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35060641E
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: