Basic Information
| Provider Information | |||||||||
| NPI: | 1154322741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLINAS | ||||||||
| FirstName: | PANAYIOTIS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 COLE AVE | ||||||||
| Address2: | CQCH BILLING DEPT | ||||||||
| City: | BISBEE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856031327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204326452 | ||||||||
| FaxNumber: | 5204328018 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E 5TH ST | ||||||||
| Address2: | CQCH BILLING DEPT | ||||||||
| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856072859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203647659 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 23114 | AZ | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 322214 | 05 | AZ | MEDICAID |