Healthcare Provider Details

I. General information

NPI: 1093878803
Provider Name (Legal Business Name): WILLIAM JOHN ELLIS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 J DEWEY GRAY CIR STE 302 DOCTORS HOSPITAL SPORTS MEDICINE
AUGUSTA GA
30909-6580
US

IV. Provider business mailing address

2044 MCDOWELL ST
AUGUSTA GA
30904-4171
US

V. Phone/Fax

Practice location:
  • Phone: 706-651-2270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License NumberAT000706
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: