Provider Demographics
NPI:1528078300
Name:ELLIS, ANTHONY FORREST (PT)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:FORREST
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:ANDY
Other - Middle Name:F
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 2150
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-2150
Mailing Address - Country:US
Mailing Address - Phone:912-383-0559
Mailing Address - Fax:912-383-0614
Practice Address - Street 1:808 WARD ST W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-3514
Practice Address - Country:US
Practice Address - Phone:912-383-0559
Practice Address - Fax:912-383-0614
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT 001108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000278429GMedicaid
GA000278429DMedicaid
GA000278429FMedicaid
GA000278429FMedicaid
GA000278429GMedicaid