Healthcare Provider Details

I. General information

NPI: 1851598130
Provider Name (Legal Business Name): ROBERT GARETH ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CHURCH ST N
CONCORD NC
28025-2927
US

IV. Provider business mailing address

PO BOX 2000
CONCORD NC
28026-2000
US

V. Phone/Fax

Practice location:
  • Phone: 704-403-1430
  • Fax:
Mailing address:
  • Phone: 704-403-1430
  • Fax: 704-403-1158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number201201284
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number201201284
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: