Provider Demographics
NPI:1962762708
Name:PHYSICIAN CONSULTANTS OF GEORGIA
Entity type:Organization
Organization Name:PHYSICIAN CONSULTANTS OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:KRISTIAN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-877-8115
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-28
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055819207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126259AMedicaid