Basic Information
| Provider Information | |||||||||
| NPI: | 1225016835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JELLISON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8020 CONSTITUTION PL NE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059983096 | ||||||||
| FaxNumber: | 5059983100 | ||||||||
| Practice Location | |||||||||
| Address1: | 8020 CONSTITUTION PL NE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059983096 | ||||||||
| FaxNumber: | 5059983100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 02/23/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 223452 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 01061964A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD2008-0142 | NM | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00331579 | 01 | IN | RR MEDICARE-351158723 | OTHER | 200828930 | 05 | IN | MEDICAID | 000000393001 | 01 | IN | ANTHEM-351158723 | OTHER | 000000393004 | 01 | IN | ANTHEM-352047427 | OTHER | 073867 | 01 | IN | SIHO-352047427 | OTHER | 2101688 | 05 | MA | MEDICAID | 073863 | 01 | IN | SIHO-351158723 | OTHER | 468500 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 92753337 | 05 | NM | MEDICAID | Q0433404 | 01 | IN | SHOCMO351158723-352047427 | OTHER | 000000492351 | 01 | IN | ANTHEM 203778927 | OTHER | J28632 | 01 | MA | BCBS OF MA | OTHER |