MEDICARE: MR. DOUGLAS A ELLIS PHYSICAL THERAPIST

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	225100000X	Physical Therapist	0149	NV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DL668Z	OTHER		MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265404388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS A ELLIS PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	630-296-2223
Fax Number	:	630-759-9510

Provider Business Practice Location Address
First Line	:	3233 W CHARLESTON BLVD
Second Line	:	STE 107
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1938
Country	:	US
Telephone Number	:	702-258-9381
Fax Number	:	702-258-9584

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

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	09/03/2015

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Directions to “ MR. DOUGLAS A ELLIS PHYSICAL THERAPIST” Practice Location

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