Healthcare Provider Details

I. General information

NPI: 1245228196
Provider Name (Legal Business Name): ELLIS FRAZIER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 INDIAN RIDGE DR
PIKETON OH
45661-9654
US

IV. Provider business mailing address

100 INDIAN RIDGE DR
PIKETON OH
45661-9654
US

V. Phone/Fax

Practice location:
  • Phone: 740-289-1548
  • Fax: 740-289-3989
Mailing address:
  • Phone: 740-289-1548
  • Fax: 740-289-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35052676F
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: