Basic Information
| Provider Information | |||||||||
| NPI: | 1316002546 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETER S. ELLIS, M.D., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5505 VIA SORENTO | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933069567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613737503 | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 34TH ST | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933012237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613274647 | ||||||||
| FaxNumber: | 6613268507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6613274647 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0104110 | 05 | CA | MEDICAID |