Provider Demographics
NPI:1487745964
Name:ELLIS, BRYAN JON (DO)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:JON
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1270 SOLUTIONS CENTER
Mailing Address - Street 2:PO BOX 771270
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1002
Mailing Address - Country:US
Mailing Address - Phone:513-542-6898
Mailing Address - Fax:513-542-7972
Practice Address - Street 1:10506 MONTGOMERY RD STE 304
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4400
Practice Address - Country:US
Practice Address - Phone:513-853-9000
Practice Address - Fax:513-984-2692
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005984208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2192050Medicaid
OH2192050Medicaid
OHEL4223151Medicare PIN