Provider Demographics
NPI:1780703561
Name:MATTHEW S ELLIS MD PA
Entity type:Organization
Organization Name:MATTHEW S ELLIS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-333-5911
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6400 W NEWBERRY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605
Practice Address - Country:US
Practice Address - Phone:352-333-5911
Practice Address - Fax:353-333-4684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME965202083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003355400Medicaid
FLAB870Medicare PIN