Basic Information
| Provider Information | |||||||||
| NPI: | 1407199540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAMPLIN | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | ELLWORTH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | UW RADIOLOGY DEPT RR 210 | ||||||||
| Address2: | 1959 N.E. PACIFIC STREET, BOX 357115 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981957115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065986483 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5230 CENTRE AVE | ||||||||
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| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152321304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126232465 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2013 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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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 | 2085R0204X | MD2019-0524 | NM | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | MD2019-0524 | NM | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.