1043297062 NPI number — DR. EDWARD R. WILLS MD

Table of content: NICOLE LOPES (NPI 1962161067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043297062 NPI number — DR. EDWARD R. WILLS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLS
Provider First Name:
EDWARD
Provider Middle Name:
R.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043297062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14275 MIDWAY RD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
ADDISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75001-3614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-932-8029
Provider Business Mailing Address Fax Number:
610-271-4245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2560 N. SHADELAND AVE.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46219-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-275-8072
Provider Business Practice Location Address Fax Number:
317-275-8018
Provider Enumeration Date:
12/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  01026745A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000092727 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000012973 . This is a "MPLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100199740A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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