Basic Information
| Provider Information | |||||||||
| NPI: | 1548224983 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | ALFRED | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368327000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 E WENDOVER AVE STE 211 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368323088 | ||||||||
| FaxNumber: | 3368323080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 9501233 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 9501233 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 60902 | 01 | NC | MEDCOST | OTHER | 5423138 | 01 | NC | AETNA | OTHER | 12317 | 01 | NC | PARTNERS MEDICARE | OTHER | 8930469 | 05 | NC | MEDICAID | 30469 | 01 | NC | BCBS NC | OTHER |