MEDICARE: DR. MATTHEW D ELLISON M.D.

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	207Y00000X	Otolaryngology Physician	A67446	CA

General Provider Information

NPI Number	:	1598865438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW D ELLISON M.D.

Provider Business Mailing Address
First Line	:	3480 WAKE FOREST RD STE 404
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-7376
Country	:	US
Telephone Number	:	919-862-5730
Fax Number	:	919-862-5733

Provider Business Practice Location Address
First Line	:	3480 WAKE FOREST RD STE 404
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-7376
Country	:	US
Telephone Number	:	919-862-5730
Fax Number	:	919-862-5733

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	12/27/2021

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