=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366440919
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLIS GERARD MAIN D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2005
-----------------------------------------------------
Last Update Date | 10/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 327 W AVENUE J
-----------------------------------------------------
City | ROBSTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78380-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-387-9233
-----------------------------------------------------
Fax | 361-387-8992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10426
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78460-0426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-387-9233
-----------------------------------------------------
Fax | 361-387-8992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | J2176
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | J2176
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------