MEDICARE: MICHAEL R ELLWOOD MS, PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	000547	CT

General Provider Information

NPI Number	:	1073726691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL R ELLWOOD MS, PA-C

Provider Business Mailing Address
First Line	:	6030 SELWOOD PL
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22152-1412
Country	:	US
Telephone Number	:	703-569-1451
Fax Number	:

Provider Business Practice Location Address
First Line	:	6030 SELWOOD PL
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22152-1412
Country	:	US
Telephone Number	:	703-569-1451
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	07/08/2007

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