MEDICARE: JOSEPH MAURICE ELLIS JR.

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	172A00000X	Driver	UZ585762	OH

General Provider Information

NPI Number	:	1447021449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH MAURICE ELLIS JR.

Provider Business Mailing Address
First Line	:	1770 HAMILTON ST
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43607-4382
Country	:	US
Telephone Number	:	419-699-5734
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 S DETROIT AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43609-1931
Country	:	US
Telephone Number	:	419-699-5734
Fax Number	:

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

Provider Enumeration Date	:	01/10/2024
Last Update Date	:	01/10/2024

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