Provider Demographics
NPI:1366428484
Name:ELLIS, GEORGE JR (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 BOARDMAN-CANFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512
Mailing Address - Country:US
Mailing Address - Phone:330-965-0832
Mailing Address - Fax:330-965-0155
Practice Address - Street 1:910 BOARDMAN-CANFIELD ROAD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512
Practice Address - Country:US
Practice Address - Phone:330-965-0832
Practice Address - Fax:330-965-0155
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060641207P00000X
OH35060641E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0705617Medicare PIN
EL0705614Medicare PIN
F13547Medicare UPIN