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NPI Code Detail

MEDICARE: ELLIS KEITH GARRETT PA-C

MEDICARE: ELLIS KEITH GARRETT PA-C
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
1363AS0400XSurgical Physician AssistantPA0001998FL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P00040948OTHERFLRAILROAD MEDICARE PROVIDE

General Provider Information

NPI Number : 1639162142
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELLIS KEITH GARRETT PA-C
Provider Business Mailing Address
First Line : PO BOX 21686
Second Line : CARE OF UNITED SURGICAL ASSISTANTS, INC.
City : TAMPA
State : FL
Zip : 33622-1686
Country : US
Telephone Number : 877-872-5788
Fax Number : 866-698-7272
Provider Business Practice Location Address
First Line : 12880 COMMODITY PL
Second Line : CARE OF UNITED SURGICAL ASSISTANTS, INC.
City : TAMPA
State : FL
Zip : 33626-3101
Country : US
Telephone Number : 877-872-5788
Fax Number : 866-698-7272
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/30/2005
Last Update Date : 07/09/2007

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