Provider Demographics
NPI:1376853507
Name:JOHN F. ELLENBERG, M.D., P.C.
Entity Type:Organization
Organization Name:JOHN F. ELLENBERG, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:ELLENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-261-0447
Mailing Address - Street 1:2500 STARLING ST
Mailing Address - Street 2:406
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4265
Mailing Address - Country:US
Mailing Address - Phone:912-261-0447
Mailing Address - Fax:912-261-1847
Practice Address - Street 1:2500 STARLING ST
Practice Address - Street 2:406
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4265
Practice Address - Country:US
Practice Address - Phone:912-261-0447
Practice Address - Fax:912-261-1847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021451207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000384315AMedicaid
GA000384315AMedicaid
GA16BDBKWMedicare PIN