Provider Demographics
NPI:1871506386
Name:ELLIN, RICHARD S (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
Last Name:ELLIN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:828-526-1285
Practice Address - Street 1:455 PHILIP BLVD STE 130
Practice Address - Street 2:KAISER PERMANENTE LAWRENCEVILLE MEDICAL OFFICE
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8768
Practice Address - Country:US
Practice Address - Phone:678-985-5000
Practice Address - Fax:828-526-2914
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2016-01385207R00000X
GA025604207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCT328A194OtherMEDICARE PTAN
D45279Medicare UPIN