Provider Demographics
NPI:1871771360
Name:BRENT R. ELLMERS, MD
Entity type:Organization
Organization Name:BRENT R. ELLMERS, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:R
Authorized Official - Last Name:ELLMERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-891-1056
Mailing Address - Street 1:700 TILGHMAN DRIVE
Mailing Address - Street 2:SUITE 718
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-5519
Mailing Address - Country:US
Mailing Address - Phone:910-891-1056
Mailing Address - Fax:910-891-4896
Practice Address - Street 1:700 TILGHMAN DRIVE
Practice Address - Street 2:SUITE 718
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-5519
Practice Address - Country:US
Practice Address - Phone:910-891-1056
Practice Address - Fax:910-891-4896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5947090001Medicare NSC