Provider Demographics
NPI:1760483770
Name:ELLINGTON MEMORIAL CLINIC, LLP
Entity Type:Organization
Organization Name:ELLINGTON MEMORIAL CLINIC, LLP
Other - Org Name:ELLINGTON RURAL HEALTH CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:G
Authorized Official - Last Name:CARNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-796-2868
Mailing Address - Street 1:1011 SOUTH WILLIAMS STREET
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-3245
Mailing Address - Country:US
Mailing Address - Phone:903-796-2868
Mailing Address - Fax:903-796-0826
Practice Address - Street 1:1011 SOUTH WILLIAMS STREET
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-3245
Practice Address - Country:US
Practice Address - Phone:903-796-2868
Practice Address - Fax:903-796-0826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX04709OtherBCBS
TX133389002Medicaid
TX133389004Medicaid
TX88966OtherBCBS
TX133389005Medicaid
TX133389005Medicaid
TXCD1986Medicare PIN
C19897Medicare UPIN
TX88966OtherBCBS