Individual
DR. MARK FREDERICK ELLISON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2142 W BROAD ST, BUILDING 200, SUITE 200, ATHENS, GA 30606-3506
(706) 612-9401
(706) 612-9410
Mailing address
PO BOX 6127, ATHENS, GA 30604-6127
(706) 612-9401
(706) 612-9410
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
026107
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000370994F
—
GA
Enumeration date
07/14/2005
Last updated
03/07/2023
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