Healthcare Provider Details

I. General information

NPI: 1306822408
Provider Name (Legal Business Name): ELLEN NMN MACE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLEN MACE LEIBSON D.O.

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INTERSTATE 81 & 901 W FCI SCHUYLKILL - HEALTH SERVICES
MINERSVILLE PA
17954-0700
US

IV. Provider business mailing address

PO BOX 700 FCI SCHUYLKILL - HEALTH SERVICES
MINERSVILLE PA
17954-0700
US

V. Phone/Fax

Practice location:
  • Phone: 570-544-7100
  • Fax: 570-544-7224
Mailing address:
  • Phone: 570-544-7100
  • Fax: 570-544-7224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1904
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: