=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376898122
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLIS CHRISTIAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2012
-----------------------------------------------------
Last Update Date | 04/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 N LAWNWOOD CIR
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34950-4884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-302-3977
-----------------------------------------------------
Fax | 772-673-8502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 SE HILLMOOR DR STE 407
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-7561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-335-9600
-----------------------------------------------------
Fax | 772-398-7971
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 125061363
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | ME139552
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number | ME139552
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------