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General NPI Number Information
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NPI Number | 1184870164
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Entity Type | Organization
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Legal Business Name | ENRIQUE ELLENBOGEN, M.D. INC
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Dates
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Enumeration Date | 08/11/2008
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Last Update Date | 08/22/2008
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Provider Practice Location Address
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Address Line | 700 S STANFIELD RD SUITE B
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City | TROY
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State | OH
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Zip | 45373-2569
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Country | US
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Telephone | 937-335-7121
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Fax | 937-335-7124
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Provider Business Mailing Address
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Address Line | 700 S STANFIELD RD SUITE B
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City | TROY
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State | OH
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Zip | 45373-2569
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Country | US
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Telephone | 937-335-7121
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Fax | 937-335-7124
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DONNA JEAN ZIMMERMAN
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Credential |
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Telephone | 937-335-7121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 35100246
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License Number State | OH
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