Healthcare Provider Details

I. General information

NPI: 1689776205
Provider Name (Legal Business Name): ELLSWORTH JACK REMSON JD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 08/15/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMANCIPATION DR
HAMPTON VA
23667-0001
US

IV. Provider business mailing address

15753 WHIRLAND DR
MIDLOTHIAN VA
23112-5255
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax:
Mailing address:
  • Phone: 985-520-7507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number0101051340
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101051340
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101051340
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number020915
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: