Healthcare Provider Details

I. General information

NPI: 1376509323
Provider Name (Legal Business Name): COREY JAMES ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E APPLE ST SUITE 2200
DAYTON OH
45409-2939
US

IV. Provider business mailing address

725 UNIVERSITY BLVD
DAYTON OH
45435-0001
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-2091
  • Fax: 937-208-6141
Mailing address:
  • Phone: 937-245-7100
  • Fax: 937-245-7999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35084741
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number35.084741
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: