Provider Demographics
NPI:1083641757
Name:ELLIS, JENNIFER T (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6308
Mailing Address - Fax:
Practice Address - Street 1:717 SE MAIN ST
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3237
Practice Address - Country:US
Practice Address - Phone:864-522-5400
Practice Address - Fax:864-522-5405
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC245185Medicaid
H96482Medicare UPIN
SC8157Medicare PIN