Provider Demographics
NPI:1780630574
Name:ELLISON, THOMAS S (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:ELLISON
Suffix:
Gender:M
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 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-652-8226
Mailing Address - Fax:
Practice Address - Street 1:4040 HIGHWAY 17 UNIT 301
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5098
Practice Address - Country:US
Practice Address - Phone:843-652-8205
Practice Address - Fax:843-652-8215
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97-00936207XS0117X
SCTL24839207XS0117X
SC24839207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ08866Medicaid
NC8910500Medicaid
NC8910500Medicaid
NC2239444DMedicare PIN
SCAA8647A204Medicare Oscar/Certification