Provider Demographics
NPI:1245336932
Name:ELLIS, RICHARD K (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:K
Last Name:ELLIS
Suffix:
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:PO BOX 118008
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29423-8008
Mailing Address - Country:US
Mailing Address - Phone:843-374-3621
Mailing Address - Fax:843-374-3624
Practice Address - Street 1:148 SAULS ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2631
Practice Address - Country:US
Practice Address - Phone:843-374-3621
Practice Address - Fax:843-374-3624
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC211826Medicaid
SCP01055600OtherRR PTAN
SC7555Medicare PIN
SCH32459Medicare UPIN
SCP01055600OtherRR PTAN
SC211826Medicaid