Provider Demographics
NPI:1093878803
Name:ELLIS, WILLIAM JOHN (ATC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JOHN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2044 MCDOWELL ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3624 J DEWEY GRAY CIR STE 302
Practice Address - Street 2:DOCTORS HOSPITAL SPORTS MEDICINE
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6580
Practice Address - Country:US
Practice Address - Phone:706-651-2270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT000706283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital