Provider Demographics
NPI:1730154659
Name:ELLISON, AARON GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:AARON
Middle Name:GREGORY
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 601067
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1067
Mailing Address - Country:US
Mailing Address - Phone:704-801-3050
Mailing Address - Fax:704-801-3026
Practice Address - Street 1:9908 COULOAK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-8678
Practice Address - Country:US
Practice Address - Phone:704-801-3050
Practice Address - Fax:704-801-3026
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-00205207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1730154659Medicaid
NC5903142Medicaid
NC2060585Medicare PIN
NCI67271Medicare UPIN
NC5903142Medicaid