Healthcare Provider Details

I. General information

NPI: 1043257231
Provider Name (Legal Business Name): GREGORY CARL ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 EASTCHESTER DR
HIGH POINT NC
27265-3116
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-481-1830
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35118
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8930633
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: