Basic Information
| Provider Information | |||||||||
| NPI: | 1568824209 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAMES B ELLIS MDPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12446 WEST AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782162517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105251668 | ||||||||
| FaxNumber: | 2105251669 | ||||||||
| Practice Location | |||||||||
| Address1: | 12446 WEST AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782162517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105251668 | ||||||||
| FaxNumber: | 2105251669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 09/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2105251668 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 356652301 | 05 | TX | MEDICAID |