1821183542 NPI number — STUART R WILLES M.D.

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 1821183542 NPI number — STUART R WILLES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLES
Provider First Name:
STUART
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1821183542
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 FAIRMOUNT AVENUE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-494-7921
Provider Business Mailing Address Fax Number:
410-902-8247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9103 FRANKLIN SQUARE DR
Provider Second Line Business Practice Location Address:
300
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21237-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-682-5282
Provider Business Practice Location Address Fax Number:
410-682-5286
Provider Enumeration Date:
10/04/2006

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: 207RC0200X , with the licence number:  D0036663 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: D0036663 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 345806 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 290008363 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4800203 . This is a "UNITED HEALTHCARE MCO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42428624 420A . This is a "BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0009 E554 . This is a "BLUE CHOICE/FEP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1427796 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 533281800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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