Provider Demographics
NPI:1730150194
Name:ELLIS, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 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 1:1765 OLD WEST BROAD ST
Practice Address - Street 2:BLDG 1 STE 200
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2867
Practice Address - Country:US
Practice Address - Phone:706-208-0451
Practice Address - Fax:706-208-0147
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036525208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000526479BMedicaid
GAF53291Medicare UPIN
GA000526479BMedicaid