Provider Demographics
NPI:1497599302
Name:ELLIS, CHASE JAY
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:JAY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 E LONG ST APT 222
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1978
Mailing Address - Country:US
Mailing Address - Phone:740-248-1903
Mailing Address - Fax:
Practice Address - Street 1:255 E LONG ST APT 222
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1978
Practice Address - Country:US
Practice Address - Phone:740-248-1903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUH318141343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)