MEDICARE: DR. IAN ALEXANDER MELLIS MD, PHD

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	207ZC0006X	Clinical Pathology Physician	327229	NY
2	207ZB0001X	Blood Banking & Transfusion Medicine Physician	327229	NY
3	207ZP0104X	Chemical Pathology Physician	327229	NY
4	207ZP0105X	Clinical Pathology/Laboratory Medicine Physician	327229	NY

General Provider Information

NPI Number	:	1366022915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IAN ALEXANDER MELLIS MD, PHD

Provider Business Mailing Address
First Line	:	630 WEST 168TH ST
Second Line	:	PH 1564W
City	:	NEW YORK
State	:	NY
Zip	:	10032
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	622 W 168TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10032-3720
Country	:	US
Telephone Number	:	212-305-5697
Fax Number	:

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

Provider Enumeration Date	:	04/08/2021
Last Update Date	:	10/24/2025

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