Healthcare Provider Details

I. General information

NPI: 1639769672
Provider Name (Legal Business Name): ELLSWORTH FOOT AND ANKLE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2021
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 FAIRBURN RD SW STE 100
ATLANTA GA
30331-2012
US

IV. Provider business mailing address

9980 S 300 W STE 300
SANDY UT
84070-3654
US

V. Phone/Fax

Practice location:
  • Phone: 404-618-6077
  • Fax: 801-253-6888
Mailing address:
  • Phone: 801-253-6886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYAN ELLSWORTH
Title or Position: CEO
Credential: DPM
Phone: 801-253-6886