Provider Demographics
NPI:1528187556
Name:ELLIS, ADRIENNE CHARLENE (MD)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:CHARLENE
Last Name:ELLIS
Suffix:
Gender:F
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:2801 WOODRUFF RD STE 201
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-4807
Practice Address - Country:US
Practice Address - Phone:864-849-3466
Practice Address - Fax:864-849-9166
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC116730207V00000X
SC29737207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC198716OtherMEDCOST
SCP00921760OtherRAILROAD MEDICARE
SC297379Medicaid
SCAA18796162OtherMEDICARE PIN
NC5907404Medicaid
SC7953931OtherAETNA
SCP00921760OtherRAILROAD MEDICARE
SC7953931OtherAETNA