=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316389836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIAN CONSULTANTS OF GEORGIA INTERVENTIONAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2013
-----------------------------------------------------
Last Update Date | 11/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1445 GEORGIA AVE SUITE 1
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31201-7610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-250-1328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4461
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31208-4461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-250-1328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROPRIETOR
-----------------------------------------------------
Name | DR. REUBEN KRIS ELLIS
-----------------------------------------------------
Credential | M.D., FASN
-----------------------------------------------------
Telephone | 478-250-1328
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 055819
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number | 055819
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 055819
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------