Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 256992 | NY |
NPI | 1003019514 |
---|---|
Provider Name | Brennan Ellis |
First Address | Syracuse, NY 13210-2342 |
Second Address | Syracuse, NY 13210-2342 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2007 |
Last Update Date | 08/04/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03248175 | (05) | NY |
P00890823 | RAILROAD MEDICARE (01) | NY |