MEDICARE: KENT ROBERT ELLIS MD

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	207P00000X	Emergency Medicine Physician	25MA04633700	NJ

General Provider Information

NPI Number	:	1649204512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENT ROBERT ELLIS MD

Provider Business Mailing Address
First Line	:	1841 WOODFIELD RD
Second Line	:
City	:	MARTINSVILLE
State	:	NJ
Zip	:	08836-2344
Country	:	US
Telephone Number	:	732-868-0545
Fax Number	:

Provider Business Practice Location Address
First Line	:	1841 WOODFIELD RD
Second Line	:
City	:	MARTINSVILLE
State	:	NJ
Zip	:	08836-2344
Country	:	US
Telephone Number	:	732-868-0545
Fax Number	:

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/20/2015

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