Individual
KEITH ERRETT ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1107 E 66TH ST, SAVANNAH, GA 31404-5701
(912) 350-8404
(912) 350-8067
Mailing address
1107 E 66TH ST, SAVANNAH, GA 31404-5701
(912) 350-8404
(912) 350-8067
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
26106
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000526578B
—
GA
05
—
000526578C
—
GA
01
—
080164682
RR MEDICARE
GA
01
—
582162071-014
HMHS/TRICARE SOUTH
—
01
—
CH5121
RR MEDICARE GROUP ID
GA
05
—
G26106
—
SC
01
—
GRP3905
GA MEDICARE GROUP ID
GA
Enumeration date
01/09/2007
Last updated
03/03/2014
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