1811996028 NPI number — DR. CHARLES J WILLEY MD

Table of content: DR. CHARLES J WILLEY MD (NPI 1811996028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811996028 NPI number — DR. CHARLES J WILLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLEY
Provider First Name:
CHARLES
Provider Middle Name:
J
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:
1811996028
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/20/2006
NPI Reactivation Date:
06/20/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9915 KENNERLY RD
Provider Second Line Business Mailing Address:
SUITE J
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63128-2703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-843-4794
Provider Business Mailing Address Fax Number:
314-843-9256

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9915 KENNERLY RD
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-2703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-843-4794
Provider Business Practice Location Address Fax Number:
314-843-9256
Provider Enumeration Date:
07/19/2005

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: 174400000X , with the licence number:  13351 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0407220 . This is a "UHC ST LOUIS MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 08221955 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 138779 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: A13558 . This is a "MERCY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4001190 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 000000010004 . This is a "ESSENCE ST LOUIS MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0403389 . This is a "UHC COLUMBIA IL" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 127507 . This is a "GHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0400221 . This is a "UHC MEDICARE COMPLETE IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 000000012458 . This is a "ESSENCE COLUMBIA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0403389 . This is a "UHC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 25662 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0400101 . This is a "UHC MEDICARE COMPLETE MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 25662 . This is a "BCBS IL/MO TRI-ST" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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