Healthcare Provider Details

I. General information

NPI: 1871506386
Provider Name (Legal Business Name): RICHARD S ELLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 01/06/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 PHILIP BLVD STE 130 KAISER PERMANENTE LAWRENCEVILLE MEDICAL OFFICE
LAWRENCEVILLE GA
30046-8768
US

IV. Provider business mailing address

3495 PIEDMONT RD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 678-985-5000
  • Fax: 828-526-2914
Mailing address:
  • Phone: 404-504-5678
  • Fax: 828-526-1285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2016-01385
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number025604
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: