Provider Demographics
NPI:1962647628
Name:COLLINS, ELLIS MORGAN JR (MD)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:MORGAN
Last Name:COLLINS
Suffix:JR
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 1:1301 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-3922
Mailing Address - Country:US
Mailing Address - Phone:870-633-5761
Mailing Address - Fax:870-633-5761
Practice Address - Street 1:1301 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-3922
Practice Address - Country:US
Practice Address - Phone:870-633-5761
Practice Address - Fax:870-633-5761
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-2851207QA0505X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine