Provider Demographics
NPI:1841261294
Name:MARK A ELLIS, MD, PC
Entity type:Organization
Organization Name:MARK A ELLIS, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-208-0451
Mailing Address - Street 1:PO BOX 7577
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-7577
Mailing Address - Country:US
Mailing Address - Phone:706-208-0451
Mailing Address - Fax:706-208-0147
Practice Address - Street 1:1500 LANGFORD MEDICAL DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-6220
Practice Address - Country:US
Practice Address - Phone:706-208-0451
Practice Address - Fax:706-208-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207LP2900X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6408440001Medicare NSC