Provider Demographics
NPI:1669570321
Name:ELLIS, ROSEGENEE MCLARIN (MD)
Entity type:Individual
Prefix:
First Name:ROSEGENEE
Middle Name:MCLARIN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 VERNON RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4131
Mailing Address - Country:US
Mailing Address - Phone:770-793-7899
Mailing Address - Fax:770-793-7856
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:770-793-7899
Practice Address - Fax:770-793-7856
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062836207R00000X, 208M00000X
GA62836207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA372128447Medicaid
GA372128447Medicaid
GAI71149Medicare UPIN