Basic Information
| Provider Information | |||||||||
| NPI: | 1598895518 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLIS HOME OXYGEN & MEDICAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELLIS HOME OXYGEN & MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 W GERMANTOWN PIKE STE 250 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194621437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106306357 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 925 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243544117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2767836868 | ||||||||
| FaxNumber: | 2767833357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | GRIGGS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4072060040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AEROCARE HOLDINGS LLC | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 0206008222 | VA | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 009135618 | 05 | VA | MEDICAID |