Healthcare Provider Details

I. General information

NPI: 1831176072
Provider Name (Legal Business Name): KERRY ALLEN WILLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 LIVE OAK ST SUITE C
BEAUFORT NC
28516
US

IV. Provider business mailing address

1620 LIVE OAK ST SUITE C
BEAUFORT NC
28516
US

V. Phone/Fax

Practice location:
  • Phone: 252-728-5737
  • Fax: 252-728-5739
Mailing address:
  • Phone: 252-728-5737
  • Fax: 252-728-5739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30580
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: