1871583609 NPI number — DR. DOUGLAS H ELLEBY DPM

Table of content: DR. DOUGLAS H ELLEBY DPM (NPI 1871583609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871583609 NPI number — DR. DOUGLAS H ELLEBY DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLEBY
Provider First Name:
DOUGLAS
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871583609
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 CIRCLE 75 PKWY.
Provider Second Line Business Mailing Address:
STE. 900
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-3084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-384-0284
Provider Business Mailing Address Fax Number:
404-446-1957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3825 MEDICAL PARK DR.
Provider Second Line Business Practice Location Address:
STE. 200
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30106-6831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-745-5101
Provider Business Practice Location Address Fax Number:
770-745-9740
Provider Enumeration Date:
10/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  000433 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: POD000433 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000138993A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1756385 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".