Provider Demographics
NPI:1871510644
Name:ELLIS, MILES WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MILES
Middle Name:WAYNE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 CREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-3507
Mailing Address - Country:US
Mailing Address - Phone:706-324-4065
Mailing Address - Fax:
Practice Address - Street 1:4401 RIVER CHASE DR
Practice Address - Street 2:EMERGENCY DEPT.
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-7483
Practice Address - Country:US
Practice Address - Phone:334-732-3000
Practice Address - Fax:334-732-3020
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG15145Medicare UPIN