=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023230018
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBIN SAMUEL ELLIS D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 243 WEST END AVENUE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-595-1100
-----------------------------------------------------
Fax | 212-595-1797
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 W. 72ND STREET APT. 20D
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-4166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-496-6397
-----------------------------------------------------
Fax | 212-595-1797
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 042362
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------