MEDICARE: DR. JON MICHAEL ELLIS M.D.

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	207X00000X	Orthopaedic Surgery Physician	J9580	TX

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	:	1982600193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON MICHAEL ELLIS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 848491
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-8491
Country	:	US
Telephone Number	:	254-202-9330
Fax Number	:	254-202-9349

Provider Business Practice Location Address
First Line	:	140 HILLCREST MEDICAL BLVD STE 2
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76712-8897
Country	:	US
Telephone Number	:	254-741-1400
Fax Number	:	254-741-1428

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	09/25/2020

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