Healthcare Provider Details

I. General information

NPI: 1093805392
Provider Name (Legal Business Name): JOE CAREY ELLINGTON JR. PH.D., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 12/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 UNDERCLIFF TER
PRINCETON WV
24740-2174
US

IV. Provider business mailing address

613 PIGEON ROOST TRL
PRINCETON WV
24740-4247
US

V. Phone/Fax

Practice location:
  • Phone: 304-425-3800
  • Fax: 304-487-3914
Mailing address:
  • Phone: 304-487-6526
  • Fax: 304-487-3914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20877
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101232504
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number9500564
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301057671
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: