Individual
DR. JACK BRADLEY ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
1120 15TH ST, AUGUSTA, GA 30912
(706) 721-8623
Mailing address
1499 WALTON WAY STE 1400, AUGUSTA, GA 30901-2603
(703) 724-6100
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
072627
GA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
03/26/2011
Last updated
05/31/2018
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