Provider Demographics
NPI:1295044758
Name:MICHAEL ELLERSON
Entity type:Organization
Organization Name:MICHAEL ELLERSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-615-2500
Mailing Address - Street 1:8867 HIGHLAND RD # 3C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-6856
Mailing Address - Country:US
Mailing Address - Phone:225-615-2500
Mailing Address - Fax:
Practice Address - Street 1:231 CRESTVIEW AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70807-2532
Practice Address - Country:US
Practice Address - Phone:225-615-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LANONEOtherHAVE NOT APPLIED YET