Healthcare Provider Details

I. General information

NPI: 1700970357
Provider Name (Legal Business Name): GREGORY T. ELLISON, M.D.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 B HARPER STREET
AUGUSTA GA
30901
US

IV. Provider business mailing address

1430 B HARPER STREET
AUGUSTA GA
30901
US

V. Phone/Fax

Practice location:
  • Phone: 706-724-5451
  • Fax: 706-724-9562
Mailing address:
  • Phone: 706-724-5451
  • Fax: 706-724-9562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number024806
License Number StateGA

VIII. Authorized Official

Name: GREGORY T ELLISON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 706-724-5451