Provider Demographics
NPI:1679597736
Name:RICHARDSON, EMILY ELLIS (MD)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:ELLIS
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:EMILY
Other - Middle Name:ANN
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1230 JOHNSON FERRY PL
Mailing Address - Street 2:SUITE A-10
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2048
Mailing Address - Country:US
Mailing Address - Phone:678-560-0511
Mailing Address - Fax:678-560-0739
Practice Address - Street 1:1230 JOHNSON FERRY PL
Practice Address - Street 2:SUITE A-10
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2048
Practice Address - Country:US
Practice Address - Phone:678-560-0511
Practice Address - Fax:678-560-0739
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I080124OtherMEDICARE
BE7343495OtherFEDERAL DEA #
SCH76691Medicare UPIN