Provider Demographics
NPI:1043361934
Name:JERI ELLIS MD MPH PC
Entity type:Organization
Organization Name:JERI ELLIS MD MPH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERI
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-604-9595
Mailing Address - Street 1:5835 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-7001
Mailing Address - Country:US
Mailing Address - Phone:405-816-3311
Mailing Address - Fax:405-634-7577
Practice Address - Street 1:5835 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-7001
Practice Address - Country:US
Practice Address - Phone:405-816-3311
Practice Address - Fax:405-634-7577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK569535528001OtherBCBS
OK200049610AMedicaid
OK200075590BMedicaid
OKI16371Medicare UPIN
OK200075590BMedicaid