# PHYSICIAN CONSULTANTS OF GEORGIA INTERVENTIONAL LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** MIDTOWN VASCULAR CENTER
- **Organization subpart:** No

## Provider details

- **NPI number:** 1316389836
- **Authorized official:** DR. REUBEN KRIS ELLIS M.D., FASN (PROPRIETOR)
- **Authorized official phone:** (478) 250-1328

## Contact information

- **Practice address:** 1445 GEORGIA AVE, SUITE 1, MACON, GA 31201-7610
- **Practice address phone:** (478) 250-1328
- **Mailing address:** PO BOX 4461, MACON, GA 31208-4461
- **Mailing address phone:** (478) 250-1328

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA1903X | Ambulatory Surgical Clinic/Center | 055819 | GA | — |
| 261QE0700X | End-Stage Renal Disease (ESRD) Treatment Clinic/Center | 055819 | GA | — |
| 261QM2500X | Medical Specialty Clinic/Center | 055819 | GA | Yes |

## Other

- **Enumeration date:** 07/25/2013
- **Last updated:** 11/19/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 003124971A | — | GA |