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General NPI Number Information
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NPI Number | 1215271234
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Entity Type | Individual
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Provider Name | MARK T ELLISON DC PT
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Gender | Male
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 11/15/2012
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Provider Practice Location Address
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Address Line | 761 LAKELAND CT
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City | CARMEL
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State | IN
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Zip | 46032-1205
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Country | US
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Telephone | 317-418-0285
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Fax |
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Provider Business Mailing Address
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Address Line | 761 LAKELAND CT
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City | CARMEL
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State | IN
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Zip | 46032-1205
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Country | US
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Telephone | 317-418-0285
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 08001711A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 05005146A
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License Number State | IN
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