Healthcare Provider Details

I. General information

NPI: 1841261294
Provider Name (Legal Business Name): MARK A ELLIS, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LANGFORD MEDICAL DRIVE SUITE 200
BOGART GA
30622-6220
US

IV. Provider business mailing address

PO BOX 7577
ATHENS GA
30604-7577
US

V. Phone/Fax

Practice location:
  • Phone: 706-208-0451
  • Fax: 706-208-0147
Mailing address:
  • Phone: 706-208-0451
  • Fax: 706-208-0147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: DR. MARK A ELLIS
Title or Position: PRESIDENT
Credential: MD
Phone: 706-208-0451