Basic Information
| Provider Information | |||||||||
| NPI: | 1851848360 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JONATHAN ELLEN MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 DEPT 0420 | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018210338 | ||||||||
| FaxNumber: | 9018210341 | ||||||||
| Practice Location | |||||||||
| Address1: | 4441 E LOHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880118267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014842052 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2016 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | ELLEN | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9014842052 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.