Provider Demographics
NPI:1114969110
Name:ELLIS, REUBEN KRISTIAN (MD)
Entity type:Individual
Prefix:DR
First Name:REUBEN
Middle Name:KRISTIAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6612
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-6612
Mailing Address - Country:US
Mailing Address - Phone:478-250-1325
Mailing Address - Fax:478-254-6860
Practice Address - Street 1:1425 GEORGIA AVE STE 201A
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6546
Practice Address - Country:US
Practice Address - Phone:478-250-1325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055819207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA730346684ACMedicaid
GA730346684ADMedicaid
GA730346684KMedicaid
GA730346684TMedicaid
GA730346684UMedicaid
GA730346684XMedicaid
GA730346684PMedicaid
GA730346684SMedicaid
GA730346684ABMedicaid
GA730346684MMedicaid
GA730346684RMedicaid
GA730346684JMedicaid
GA730346684OMedicaid
GA730346684ZMedicaid
GA730346684AAMedicaid
GA730346684GMedicaid
GA730346684NMedicaid
GA730346684QMedicaid
GA730346684VMedicaid
GA730346684WMedicaid
GA730346684YMedicaid
GA730346684NMedicaid
GA730346684OMedicaid