Basic Information
| Provider Information | |||||||||
| NPI: | 1003981671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8824 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319088824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063203770 | ||||||||
| FaxNumber: | 7063203772 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 16TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319011665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063203770 | ||||||||
| FaxNumber: | 7063203772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 08/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 1014 | SC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 062835 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 112485 | 05 | AL | MEDICAID | 216425865A | 05 | GA | MEDICAID |