MEDICARE: JOHN ELLIS AGENS JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME 87099	FL
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	ME87099	FL

General Provider Information

NPI Number	:	1144287087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN ELLIS AGENS JR. MD

Provider Business Mailing Address
First Line	:	PO BOX 3064300
Second Line	:	1115 WEST CALL STREET, SUITE 1121-C
City	:	TALLAHASSEE
State	:	FL
Zip	:	32306-4300
Country	:	US
Telephone Number	:	850-645-9350
Fax Number	:	850-645-0577

Provider Business Practice Location Address
First Line	:	4449 MEANDERING WAY
Second Line	:	FSU SENIORHEALTH AT WOK
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-5740
Country	:	US
Telephone Number	:	850-644-1543
Fax Number	:	850-645-0577

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	01/13/2017

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