Provider Demographics
NPI:1003981671
Name:ELLIS, MICHAEL ALAN (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8824
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-8824
Mailing Address - Country:US
Mailing Address - Phone:706-320-3770
Mailing Address - Fax:706-320-3772
Practice Address - Street 1:2000 16TH AVENUE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1665
Practice Address - Country:US
Practice Address - Phone:706-320-3770
Practice Address - Fax:706-320-3772
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10142084P0800X
GA0628352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL112485Medicaid
GA216425865AMedicaid
AL112485Medicaid