Provider Demographics
NPI:1356317325
Name:ELLIS, PAUL T (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:T
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CLUB POINTE DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-6313
Mailing Address - Country:US
Mailing Address - Phone:864-582-7098
Mailing Address - Fax:
Practice Address - Street 1:391 SERPENTINE DR
Practice Address - Street 2:SUITE 500
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3083
Practice Address - Country:US
Practice Address - Phone:864-585-8211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17866208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F24286Medicare UPIN
SCF242864300Medicare PIN