Provider Demographics
NPI:1629427752
Name:ELLIS, MARK ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDREW
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:901 RIVERFRONT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-2198
Mailing Address - Country:US
Mailing Address - Phone:423-698-8981
Mailing Address - Fax:423-697-7109
Practice Address - Street 1:901 RIVERFRONT PKWY STE 300
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-2198
Practice Address - Country:US
Practice Address - Phone:423-698-8981
Practice Address - Fax:423-697-7109
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMMD.39505 LL207Y00000X
TN63144207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology