Basic Information
| Provider Information | |||||||||
| NPI: | 1275713273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | RAYMOND | ||||||||
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| Credential: | P.T.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1715 AVENUE T | ||||||||
| Address2: | SUITE 2F | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112293429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183368206 | ||||||||
| FaxNumber: | 7183368209 | ||||||||
| Practice Location | |||||||||
| Address1: | 1655 RICHMOND AVE | ||||||||
| Address2: | SUITE B102 | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103141570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183703500 | ||||||||
| FaxNumber: | 7183709724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2007 | ||||||||
| LastUpdateDate: | 11/07/2007 | ||||||||
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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 | 225200000X | 003487-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.