Healthcare Provider Details

I. General information

NPI: 1497241269
Provider Name (Legal Business Name): EDWARD T WILLS DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 HARPER ST STE B
AUGUSTA GA
30901-0619
US

IV. Provider business mailing address

1430 HARPER ST STE B
AUGUSTA GA
30901-0619
US

V. Phone/Fax

Practice location:
  • Phone: 706-724-5451
  • Fax: 706-724-9562
Mailing address:
  • Phone: 706-724-5451
  • Fax: 706-724-9562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number79140
License Number StateGA

VIII. Authorized Official

Name: JENNIFER FINLEY
Title or Position: PRACTICE MANANGER
Credential:
Phone: 706-724-5451