=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871771360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRENT R. ELLMERS, MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2008
-----------------------------------------------------
Last Update Date | 02/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 TILGHMAN DRIVE SUITE 718
-----------------------------------------------------
City | DUNN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28334-5519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-891-1056
-----------------------------------------------------
Fax | 910-891-4896
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 TILGHMAN DRIVE SUITE 718
-----------------------------------------------------
City | DUNN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28334-5519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-891-1056
-----------------------------------------------------
Fax | 910-891-4896
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. BRENT R. ELLMERS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 910-891-1056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 9801640
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------