MEDICARE: DR. GEORGE THEMEO ELLIS

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	103TC0700X	Clinical Psychologist	LP1353	MN

General Provider Information

NPI Number	:	1821677576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE THEMEO ELLIS

Provider Business Mailing Address
First Line	:	150 SCENIC DR
Second Line	:
City	:	HOT SPRINGS
State	:	AR
Zip	:	71913-7739
Country	:	US
Telephone Number	:	612-816-7274
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 SCENIC DR
Second Line	:
City	:	HOT SPRINGS
State	:	AR
Zip	:	71913-7739
Country	:	US
Telephone Number	:	612-816-7274
Fax Number	:

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

Provider Enumeration Date	:	04/07/2021
Last Update Date	:	04/07/2021

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