1427014497 NPI number — DR. CHARLES KEITH WILLIS M.D.

Table of content: DR. CHARLES KEITH WILLIS M.D. (NPI 1427014497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427014497 NPI number — DR. CHARLES KEITH WILLIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIS
Provider First Name:
CHARLES
Provider Middle Name:
KEITH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIS
Provider Other First Name:
C.
Provider Other Middle Name:
KEITH
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1427014497
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 29568
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27429-9568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-273-2511
Provider Business Mailing Address Fax Number:
336-370-0287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
912 THIRD STREET
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27405-6967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-273-2511
Provider Business Practice Location Address Fax Number:
336-370-0287
Provider Enumeration Date:
04/26/2006

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: 2084D0003X , with the licence number:  33768 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 33768 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 130015016 . This is a "PALMETTO GBA RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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