Basic Information
| Provider Information | |||||||||
| NPI: | 1780668400 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENNIS | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95000-2456 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128448027 | ||||||||
| FaxNumber: | 2128446306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 10TH AVE | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100191147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125237165 | ||||||||
| FaxNumber: | 2125238189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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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 | 2085R0001X | 196138 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 01811072 | 05 | NY | MEDICAID |