Provider Demographics
NPI:1780678516
Name:ELLISON, GREGORY TAYLOR
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:TAYLOR
Last Name:ELLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 HARPER ST
Mailing Address - Street 2:BUILDING B
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-0617
Mailing Address - Country:US
Mailing Address - Phone:706-724-5451
Mailing Address - Fax:706-724-9562
Practice Address - Street 1:1430 HARPER ST
Practice Address - Street 2:BUILDING B
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-0617
Practice Address - Country:US
Practice Address - Phone:706-724-5451
Practice Address - Fax:706-724-9562
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024806208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG24806Medicaid
SCG24806Medicaid