Healthcare Provider Details

I. General information

NPI: 1013063445
Provider Name (Legal Business Name): HOWARD ROSS ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 DULUTH HWY STE 920
LAWRENCEVILLE GA
30046
US

IV. Provider business mailing address

PO BOX 1170
LAWRENCEVILLE GA
30046-1170
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-5250
  • Fax:
Mailing address:
  • Phone: 470-325-0159
  • Fax: 470-325-0191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number50159
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: