Healthcare Provider Details

I. General information

NPI: 1114028214
Provider Name (Legal Business Name): PATRICK M ELLIS MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6107 CRAWLEY CREEK RD.
CHAPMANVILLE WV
25508
US

IV. Provider business mailing address

PO BOX 1647
CHAPMANVILLE WV
25508-1647
US

V. Phone/Fax

Practice location:
  • Phone: 304-855-9500
  • Fax: 304-855-9525
Mailing address:
  • Phone: 304-855-9500
  • Fax: 304-855-9525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002118
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: