Provider Demographics
NPI:1700621638
Name:ELLIS, STEPHEN ALLEN JR
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ALLEN
Last Name:ELLIS
Suffix:JR
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 1:1858 ABERDEEN AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-1806
Mailing Address - Country:US
Mailing Address - Phone:740-381-2422
Mailing Address - Fax:
Practice Address - Street 1:1858 ABERDEEN AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-1806
Practice Address - Country:US
Practice Address - Phone:740-381-2422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health