Basic Information
| Provider Information | |||||||||
| NPI: | 1780652396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | OREN | ||||||||
| MiddleName: | HENRY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058205227 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1631 HOSPITAL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054240578 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 11/21/2007 | ||||||||
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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 | 207X00000X | 66-2 | NM | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | PROVO13053 | 01 | MOLINA | OTHER | 5421393 | 01 | CCN | OTHER | 10003858 | 01 | LOVELACE | OTHER | V7059 | 05 | NM | MEDICAID | NM01VP02 | 01 | NM | BCBS NM | OTHER | 2335644 | 01 | UHC | OTHER |