Healthcare Provider Details

I. General information

NPI: 1538672001
Provider Name (Legal Business Name): JERI L ELLIS MD, MPH, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 11/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N KICKAPOO AVE
SHAWNEE OK
74801-6643
US

IV. Provider business mailing address

5909 NW EXPRESSWAY STE 360
OKLAHOMA CITY OK
73132-5149
US

V. Phone/Fax

Practice location:
  • Phone: 400-581-6331
  • Fax:
Mailing address:
  • Phone: 405-470-1884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DENISE CATO
Title or Position: CONTRACTING MANAGER
Credential:
Phone: 405-470-1884