Active NPI
Charles Ellison
- Case Manager/Care Coordinator
- Provo, UT
National Provider Identifier
1225419682
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Case Manager/Care Coordinator
- License
- 179122236
- Practice address
- 750 N Freedom Blvd
Provo, UT 84601-1677 - Phone
- (801) 373-4760
- NPI assigned
- Jun 11, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Case Manager/Care Coordinator | 171M00000X | 179122236 | UT | Primary |
Addresses
Primary practice location
750 N Freedom Blvd
Provo, UT 84601-1677
Mailing address
750 N Freedom Blvd
Provo, UT 84601-1677
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 179122236 | UT | MD | Case Manager/Care Coordinator |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1433980800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1433980800000",
"number": "1225419682",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "750 N FREEDOM BLVD",
"city": "PROVO",
"state": "UT",
"postal_code": "846011677"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "750 N FREEDOM BLVD",
"city": "PROVO",
"state": "UT",
"postal_code": "846011677",
"telephone_number": "801-373-4760"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLISON",
"first_name": "CHARLES",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2015-06-11",
"last_updated": "2015-06-11",
"status": "A"
},
"taxonomies": [
{
"code": "171M00000X",
"taxonomy_group": "",
"desc": "Case Manager/Care Coordinator",
"state": "UT",
"license": "179122236",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Provo, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 11, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.