1518943943 NPI number — DR. PHILLIP MABON WILLIFORD MD

Table of content: MISTY POPE DPH (NPI 1639773898)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518943943 NPI number — DR. PHILLIP MABON WILLIFORD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIFORD
Provider First Name:
PHILLIP
Provider Middle Name:
MABON
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:
1518943943
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 344
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27102-0344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-716-2255
Provider Business Mailing Address Fax Number:
336-716-6761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4618 COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27104-3520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-716-2255
Provider Business Practice Location Address Fax Number:
336-716-6761
Provider Enumeration Date:
12/19/2005

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: 207ND0101X , with the licence number:  26483 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207NS0135X , with the licence number: 26483 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 88074 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5552 . This is a "PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5940478 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: N26483 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2005036000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4671710 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 70016802 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8988074 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64002 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".




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