MEDICARE: MR. CARL EDWARD ELLIS JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	RPH009402	GA

General Provider Information

NPI Number	:	1376667105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARL EDWARD ELLIS JR.

Provider Business Mailing Address
First Line	:	31 S GLADE RD
Second Line	:
City	:	FORT OGLETHORPE
State	:	GA
Zip	:	30742-3909
Country	:	US
Telephone Number	:	706-866-5097
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 CITY HALL DR
Second Line	:
City	:	FORT OGLETHORPE
State	:	GA
Zip	:	30742-7802
Country	:	US
Telephone Number	:	706-861-3387
Fax Number	:	706-861-3332

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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