Provider Demographics
NPI:1134391733
Name:ELLIS, RENEE ANN (MD)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:ANN
Last Name:ELLIS
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 1:121 PARK CENTRAL DRIVE SUITE 200
Mailing Address - Street 2:COLUMBIA NEPHROLOGY
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-252-9907
Mailing Address - Fax:803-252-9906
Practice Address - Street 1:121 PARK CENTRAL DRIVE SUITE 200
Practice Address - Street 2:COLUMBIA NEPHROLOGY
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-252-9907
Practice Address - Fax:803-252-9906
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31193207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC48355Medicaid
SC48355Medicaid
SC483532040Medicare PIN