Provider Demographics
NPI:1851586853
Name:ELLIS G MAIN DO PA
Entity Type:Organization
Organization Name:ELLIS G MAIN DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:MAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:361-241-6700
Mailing Address - Street 1:PO BOX 10426
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78460-0426
Mailing Address - Country:US
Mailing Address - Phone:361-241-6700
Mailing Address - Fax:
Practice Address - Street 1:3022 MCKINZIE RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-2628
Practice Address - Country:US
Practice Address - Phone:361-241-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2176207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149471801Medicaid
TX149471801Medicaid
TX00905RMedicare PIN