Provider Demographics
NPI:1821174681
Name:ELLIS, GEORGIANA K (MD)
Entity Type:Individual
Prefix:
First Name:GEORGIANA
Middle Name:K
Last Name:ELLIS
Suffix:
Gender:F
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 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SEATTLE CANCER CARE ALLIANCE
Practice Address - Street 2:825 EASTLAKE AVENUE EAST
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109
Practice Address - Country:US
Practice Address - Phone:206-288-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020969207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
5718OtherINTERNAL ID-MOTOR VEHICLE ID
WA1035781Medicaid
WA110097209OtherRAILROAD MEDICARE
WA110097209OtherRAILROAD MEDICARE
WA000107152Medicare PIN