1689228868 NPI number — EDWARD R WILLIS JR, MD

Table of Contents

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)





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