1154452019 NPI number — DERRICK L WILLIAMS

Table of content: DERRICK L WILLIAMS (NPI 1154452019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154452019 NPI number — DERRICK L WILLIAMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
DERRICK
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1154452019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 SPRINGVIEW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMMERVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29485-8108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 MEADOWOOD DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANGHORNE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19047-1616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-750-4004
Provider Business Practice Location Address Fax Number:
215-750-4322
Provider Enumeration Date:
03/09/2007

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 4846 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1760596480 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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