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General NPI Number Information
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NPI Number | 1790125615
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Entity Type | Individual
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Provider Name | MALLIKARJUNA BAGEWADI ELLUR M.D.,
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Gender | Male
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Dates
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Enumeration Date | 06/25/2013
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Last Update Date | 07/26/2024
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Provider Practice Location Address
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Address Line | 1325 SPRING ST
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City | GREENWOOD
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State | SC
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Zip | 29646-3860
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Country | US
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Telephone | 864-725-4398
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Fax | 864-725-4399
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Provider Business Mailing Address
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Address Line | 104 WELLS AVE
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City | GREENWOOD
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State | SC
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Zip | 29646-3837
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Country | US
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Telephone | 864-725-4673
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Fax | 864-725-7424
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 90953
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License Number State | SC
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