Healthcare Provider Details

I. General information

NPI: 1427014497
Provider Name (Legal Business Name): CHARLES KEITH WILLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: C. KEITH WILLIS M.D.

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 THIRD STREET SUITE 101
GREENSBORO NC
27405-6967
US

IV. Provider business mailing address

PO BOX 29568
GREENSBORO NC
27429-9568
US

V. Phone/Fax

Practice location:
  • Phone: 336-273-2511
  • Fax: 336-370-0287
Mailing address:
  • Phone: 336-273-2511
  • Fax: 336-370-0287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number33768
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number33768
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: