Healthcare Provider Details

I. General information

NPI: 1679597736
Provider Name (Legal Business Name): EMILY ELLIS RICHARDSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY ANN ELLIS M.D.

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 JOHNSON FERRY PL SUITE A-10
MARIETTA GA
30068-2048
US

IV. Provider business mailing address

1230 JOHNSON FERRY PL SUITE A-10
MARIETTA GA
30068-2048
US

V. Phone/Fax

Practice location:
  • Phone: 678-560-0511
  • Fax: 678-560-0739
Mailing address:
  • Phone: 678-560-0511
  • Fax: 678-560-0739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number060066
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: