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General NPI Number Information
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NPI Number | 1962762708
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Entity Type | Organization
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Legal Business Name | PHYSICIAN CONSULTANTS OF GEORGIA
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Dates
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Enumeration Date | 05/28/2012
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Last Update Date | 11/19/2020
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Provider Practice Location Address
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Address Line | 1425 GEORGIA AVE STE 201A
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City | MACON
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State | GA
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Zip | 31201-6546
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Country | US
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Telephone | 478-250-1325
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6612
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City | MACON
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State | GA
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Zip | 31208-6612
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Country | US
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Telephone | 478-250-1325
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Fax | 478-254-6860
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | REUBEN KRISTIAN ELLIS
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Credential | MD
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Telephone | 404-877-8115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 055819
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License Number State | GA
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