Provider Demographics
NPI:1831134428
Name:HOWARD S ELLISON MD PC
Entity type:Organization
Organization Name:HOWARD S ELLISON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:CHILDERS
Authorized Official - Last Name:LISTER
Authorized Official - Suffix:
Authorized Official - Credentials:CPRP
Authorized Official - Phone:770-922-8222
Mailing Address - Street 1:1010 EAST FREEWAY DR
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094
Mailing Address - Country:US
Mailing Address - Phone:770-922-8222
Mailing Address - Fax:770-922-2001
Practice Address - Street 1:1010 EAST FREEWAY DR
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094
Practice Address - Country:US
Practice Address - Phone:770-922-8222
Practice Address - Fax:770-922-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000193586AMedicaid
GAGRP3788Medicare PIN
D29394Medicare UPIN