Provider Demographics
NPI:1891745980
Name:ELLISON, JODY D (MD)
Entity Type:Individual
Prefix:MISS
First Name:JODY
Middle Name:D
Last Name:ELLISON
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 1:1520 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2623
Mailing Address - Country:US
Mailing Address - Phone:803-799-8407
Mailing Address - Fax:803-252-9070
Practice Address - Street 1:1520 LAUREL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2623
Practice Address - Country:US
Practice Address - Phone:803-799-8407
Practice Address - Fax:803-252-9070
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC030Medicaid
SCFQC043Medicaid
SCFQC043Medicaid
WI421892Medicare Oscar/Certification
WI421832Medicare Oscar/Certification
SCFQC030Medicaid
SCH19885Medicare UPIN