Healthcare Provider Details

I. General information

NPI: 1871591297
Provider Name (Legal Business Name): MARGARETT CONKLIN ELLISON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2005
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 S MAIN ST
MOULTRIE GA
31768-6925
US

IV. Provider business mailing address

PO BOX 2876
MOULTRIE GA
31776-2876
US

V. Phone/Fax

Practice location:
  • Phone: 229-890-3514
  • Fax:
Mailing address:
  • Phone: 229-890-3514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number62837
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberME128607
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: