Provider Demographics
NPI:1316389836
Name:PHYSICIAN CONSULTANTS OF GEORGIA INTERVENTIONAL LLC
Entity Type:Organization
Organization Name:PHYSICIAN CONSULTANTS OF GEORGIA INTERVENTIONAL LLC
Other - Org Name:MIDTOWN VASCULAR CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:KRIS
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FASN
Authorized Official - Phone:478-250-1328
Mailing Address - Street 1:PO BOX 4461
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4461
Mailing Address - Country:US
Mailing Address - Phone:478-250-1328
Mailing Address - Fax:
Practice Address - Street 1:1445 GEORGIA AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7610
Practice Address - Country:US
Practice Address - Phone:478-250-1328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055819261QA1903X, 261QE0700X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124971AMedicaid
GA003124971AMedicaid
GA511I390002Medicare PIN