Provider Demographics
NPI:1134844426
Name:ELLIS PEDIATRICS, PLLC
Entity type:Organization
Organization Name:ELLIS PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KENYANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:904-456-9240
Mailing Address - Street 1:12086 FORT CAROLINE RD STE 401
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-7640
Mailing Address - Country:US
Mailing Address - Phone:904-456-9240
Mailing Address - Fax:904-456-9231
Practice Address - Street 1:12086 FORT CAROLINE RD STE 401
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-7640
Practice Address - Country:US
Practice Address - Phone:904-456-9240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-10
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty