Provider Demographics
NPI:1306922166
Name:TOBIN, ELLIS
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:TOBIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DELMAR PL
Mailing Address - Street 2:FALK CLINIC SUITE 700
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-3218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 NEW SCOTLAND AVE
Practice Address - Street 2:FALK CLINIC SUITE 700
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-2725
Practice Address - Country:US
Practice Address - Phone:518-435-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193536207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10006051OtherCDPHP
NY01148989Medicaid
BB6335Medicare ID - Type Unspecified
NY01148989Medicaid