Provider Demographics
NPI:1356490775
Name:ELLIS, KEITH ERRETT (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ERRETT
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 1:1107 E 66TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-5701
Mailing Address - Country:US
Mailing Address - Phone:912-350-8404
Mailing Address - Fax:912-350-8067
Practice Address - Street 1:1107 E 66TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-5701
Practice Address - Country:US
Practice Address - Phone:912-350-8404
Practice Address - Fax:912-350-8067
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA26106207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000526578CMedicaid
GA000526578BMedicaid
GA080164682OtherRR MEDICARE
GACH5121OtherRR MEDICARE GROUP ID
GAGRP3905OtherGA MEDICARE GROUP ID
SCG26106Medicaid
582162071-014OtherHMHS/TRICARE SOUTH
GA080164682OtherRR MEDICARE
GACH5121OtherRR MEDICARE GROUP ID