Healthcare Provider Details

I. General information

NPI: 1184087959
Provider Name (Legal Business Name): CHAD WILLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 2ND AVE STE C2
BOWLING GREEN KY
42101-1791
US

IV. Provider business mailing address

PO BOX 2697
BOWLING GREEN KY
42102-7697
US

V. Phone/Fax

Practice location:
  • Phone: 270-780-2780
  • Fax: 270-780-2755
Mailing address:
  • Phone: 270-745-1100
  • Fax: 270-745-1156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number42665
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number56988
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number56988
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: