Basic Information
| Provider Information | |||||||||
| NPI: | 1255652525 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1240 S CEDAR CREST BLVD | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109694370 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1240 S CEDAR CREST BLVD | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109694370 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2010 | ||||||||
| LastUpdateDate: | 06/03/2013 | ||||||||
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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 | 207R00000X | MD448381 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.