Provider Demographics
NPI:1730374976
Name:ELLISON, ERNEST EDWARD (PA)
Entity type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:EDWARD
Last Name:ELLISON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4400 W 95TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2654
Mailing Address - Country:US
Mailing Address - Phone:708-422-7758
Mailing Address - Fax:708-422-8154
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2654
Practice Address - Country:US
Practice Address - Phone:708-422-7758
Practice Address - Fax:708-422-8154
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085.002980363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical