Provider Demographics
NPI:1427779073
Name:ELLISON, KEITH ANTHONY (RT(R)(CT)(ARRT))
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ANTHONY
Last Name:ELLISON
Suffix:
Gender:M
Credentials:RT(R)(CT)(ARRT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3625
Mailing Address - Country:US
Mailing Address - Phone:757-648-9284
Mailing Address - Fax:
Practice Address - Street 1:711 COURT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3625
Practice Address - Country:US
Practice Address - Phone:757-648-9284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2560082471C3401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography