Provider Demographics
NPI:1114028214
Name:ELLIS, PATRICK M (MSPT)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1647
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-1647
Mailing Address - Country:US
Mailing Address - Phone:304-855-9500
Mailing Address - Fax:304-855-9525
Practice Address - Street 1:6107 CRAWLEY CREEK RD.
Practice Address - Street 2:
Practice Address - City:CHAPMANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25508
Practice Address - Country:US
Practice Address - Phone:304-855-9500
Practice Address - Fax:304-855-9525
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7302394-000Medicaid
WV4104751Medicare PIN