Provider Demographics
NPI:1760436844
Name:GEORGE F. ELLIS, MD, INCORPORATED
Entity Type:Organization
Organization Name:GEORGE F. ELLIS, MD, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-580-3940
Mailing Address - Street 1:92 WISTERIA DR
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4956
Mailing Address - Country:US
Mailing Address - Phone:407-928-8866
Mailing Address - Fax:866-508-1691
Practice Address - Street 1:1400 S ORLANDO AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-5543
Practice Address - Country:US
Practice Address - Phone:407-580-3940
Practice Address - Fax:866-508-1691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49437208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61123Medicare UPIN
FL04678XMedicare ID - Type Unspecified