Basic Information
| Provider Information | |||||||||
| NPI: | 1356490775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ERRETT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 E 66TH ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314045701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508404 | ||||||||
| FaxNumber: | 9123508067 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 E 66TH ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314045701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508404 | ||||||||
| FaxNumber: | 9123508067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 03/03/2014 | ||||||||
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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 | 207Q00000X | 26106 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000526578C | 05 | GA | MEDICAID | 000526578B | 05 | GA | MEDICAID | 080164682 | 01 | GA | RR MEDICARE | OTHER | CH5121 | 01 | GA | RR MEDICARE GROUP ID | OTHER | GRP3905 | 01 | GA | GA MEDICARE GROUP ID | OTHER | G26106 | 05 | SC | MEDICAID | 582162071-014 | 01 | HMHS/TRICARE SOUTH | OTHER |