Provider Demographics
NPI:1487422549
Name:ELLIS, MICAH M
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:M
Last Name:ELLIS
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 1:55 MAPLE HILL DR
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-4210
Mailing Address - Country:US
Mailing Address - Phone:740-310-1354
Mailing Address - Fax:
Practice Address - Street 1:55 MAPLE HILL DR
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-4210
Practice Address - Country:US
Practice Address - Phone:740-310-1354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care