1720345184 NPI number — DR. ASHLEY GARNER ELLISON M.D.

Table of content: DR. ASHLEY GARNER ELLISON M.D. (NPI 1720345184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720345184 NPI number — DR. ASHLEY GARNER ELLISON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLISON
Provider First Name:
ASHLEY
Provider Middle Name:
GARNER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARNER
Provider Other First Name:
ASHLEY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720345184
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 KIMEL FOREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-6074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-716-1331
Provider Business Mailing Address Fax Number:
336-716-3202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 BROOKVIEW HILLS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-5661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-765-5250
Provider Business Practice Location Address Fax Number:
336-659-0953
Provider Enumeration Date:
04/23/2012

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: 2084P0800X , with the licence number:  MD.206753 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 2018-02364 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 2018-02364 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2193066 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00580093 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".