Provider Demographics
NPI:1780835298
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 - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-7025
Practice Address - Fax:864-560-7388
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108778207P00000X
SCTL33112207P00000X
SC33112207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC331126Medicaid
NC5917294Medicaid
NC5917294Medicaid
SC331126Medicaid