Healthcare Provider Details

I. General information

NPI: 1093875973
Provider Name (Legal Business Name): WENDELL K ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

682 HEMLOCK STREET SUITE 490
MACON GA
31201
US

IV. Provider business mailing address

682 HEMLOCK ST STE 490
MACON GA
31201
US

V. Phone/Fax

Practice location:
  • Phone: 478-741-1208
  • Fax: 478-741-1557
Mailing address:
  • Phone: 478-741-1208
  • Fax: 478-741-1557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number062202
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number062202
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: