Basic Information
| Provider Information | |||||||||
| NPI: | 1720281991 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVENUE | ||||||||
| Address2: | BOX 652 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852795100 | ||||||||
| FaxNumber: | 5857567752 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVENUE | ||||||||
| Address2: | BOX 652 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852795100 | ||||||||
| FaxNumber: | 5857567752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 262312 | NY | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 03383828 | 05 | NY | MEDICAID |