MEDICARE: RUDOLPH E WILLIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RH0003X	Hematology & Oncology Physician	0101233411	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00013926	OTHER	VA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	437204	OTHER	VA	ANTHEM BCBS
4	59557	OTHER	VA	OPTIMA HEALTH PLAN
5	374935	OTHER	VA	MAMSI/MDIPA

General Provider Information

NPI Number	:	1831194216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUDOLPH E WILLIS M.D.

Provider Business Mailing Address
First Line	:	355 CRAWFORD ST
Second Line	:	STE 300
City	:	PORTSMOUTH
State	:	VA
Zip	:	23704-2819
Country	:	US
Telephone Number	:	757-396-6333
Fax Number	:	757-396-6367

Provider Business Practice Location Address
First Line	:	355 CRAWFORD ST
Second Line	:	STE 300
City	:	PORTSMOUTH
State	:	VA
Zip	:	23704-2819
Country	:	US
Telephone Number	:	757-396-6333
Fax Number	:	757-396-6367

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	07/09/2007

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Directions to “ RUDOLPH E WILLIS M.D.” Practice Location

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