Healthcare Provider Details

I. General information

NPI: 1356970321
Provider Name (Legal Business Name): ALEX BLAIR ELLENBERGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5308 HARROUN RD STE 160
SYLVANIA OH
43560-2174
US

IV. Provider business mailing address

5308 HARROUN RD STE 160
SYLVANIA OH
43560-2174
US

V. Phone/Fax

Practice location:
  • Phone: 419-824-6527
  • Fax: 419-824-6529
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME174405
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35.156454
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: