Basic Information
| Provider Information | |||||||||
| NPI: | 1740349661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JON M. ELLIS, MD PA | ||||||||
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| OtherOrganizationName: | SOUTHWEST SPORTS MEDICINE AND ORTHOPAEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7030 NEW SANGER RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767123991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547741140 | ||||||||
| FaxNumber: | 2547411428 | ||||||||
| Practice Location | |||||||||
| Address1: | 7030 NEW SANGER RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767123991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547741140 | ||||||||
| FaxNumber: | 2547411428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 03/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | ROHRER | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2547411400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | J9580 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.