Healthcare Provider Details

I. General information

NPI: 1487745964
Provider Name (Legal Business Name): BRYAN JON ELLIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10506 MONTGOMERY RD STE 304
MONTGOMERY OH
45242-4400
US

IV. Provider business mailing address

1270 SOLUTIONS CENTER PO BOX 771270
CHICAGO IL
60677-1002
US

V. Phone/Fax

Practice location:
  • Phone: 513-853-9000
  • Fax: 513-984-2692
Mailing address:
  • Phone: 513-542-6898
  • Fax: 513-542-7972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34005984
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: