Provider Demographics
NPI:1699979203
Name:ROBERT G ELLISON JR MD P A
Entity type:Organization
Organization Name:ROBERT G ELLISON JR MD P A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:904-388-7521
Mailing Address - Street 1:836 PRUDENTIAL DR
Mailing Address - Street 2:SUITE 1405
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8334
Mailing Address - Country:US
Mailing Address - Phone:904-388-7521
Mailing Address - Fax:
Practice Address - Street 1:836 PRUDENTIAL DR
Practice Address - Street 2:SUITE 1405
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8334
Practice Address - Country:US
Practice Address - Phone:904-388-7521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39556174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0434438800Medicaid
FLD61757Medicare UPIN
FL0434438800Medicaid