1689228868 NPI number — EDWARD R WILLIS JR, MD

Table of content: (NPI 1033459227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689228868 NPI number — EDWARD R WILLIS JR, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD R WILLIS JR, MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1689228868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2697
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAY ST LOUIS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-467-5121
Provider Business Mailing Address Fax Number:
228-467-0208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 DRINKWATER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY ST LOUIS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-467-5121
Provider Business Practice Location Address Fax Number:
228-467-0208
Provider Enumeration Date:
07/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
228-467-5121

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com