Healthcare Provider Details

I. General information

NPI: 1730154659
Provider Name (Legal Business Name): AARON GREGORY ELLISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9908 COULOAK DR SUITE 202
CHARLOTTE NC
28216-8678
US

IV. Provider business mailing address

PO BOX 601067
CHARLOTTE NC
28260-1067
US

V. Phone/Fax

Practice location:
  • Phone: 704-801-3050
  • Fax: 704-801-3026
Mailing address:
  • Phone: 704-801-3050
  • Fax: 704-801-3026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2004-00205
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2004-00205
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: