Healthcare Provider Details

I. General information

NPI: 1720181951
Provider Name (Legal Business Name): MARK I ELLEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 ALEXANDER CIR NE
ATLANTA GA
30326-1246
US

IV. Provider business mailing address

10435 SE 170TH PL
SUMMERFIELD FL
34491-8998
US

V. Phone/Fax

Practice location:
  • Phone: 214-952-3501
  • Fax:
Mailing address:
  • Phone: 352-630-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MA06361300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD051555L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2005-01826
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberG71376
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME145025
License Number StateFL
# 6
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME145025
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number50578
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: