Provider Demographics
NPI:1528222338
Name:ELLIS W EVANS SR MD FACS PC
Entity Type:Organization
Organization Name:ELLIS W EVANS SR MD FACS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:478-475-1299
Mailing Address - Street 1:PO BOX 26040
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-6040
Mailing Address - Country:US
Mailing Address - Phone:478-475-1299
Mailing Address - Fax:478-475-0799
Practice Address - Street 1:770 PINE ST
Practice Address - Street 2:STE 220
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2173
Practice Address - Country:US
Practice Address - Phone:478-475-1299
Practice Address - Fax:478-475-0799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013745208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty