Healthcare Provider Details

I. General information

NPI: 1104835180
Provider Name (Legal Business Name): PAUL M WILLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 HECKEL RD SUITE 213
MC KEES ROCKS PA
15136-1616
US

IV. Provider business mailing address

PO BOX 240
INGOMAR PA
15127-0240
US

V. Phone/Fax

Practice location:
  • Phone: 412-771-2266
  • Fax: 412-771-2443
Mailing address:
  • Phone: 412-771-2266
  • Fax: 412-771-2443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD070567L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0018020950001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier359754
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUE SHIELD
# 3
Identifier0109675000
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerINDEPENDENCE BLUE SHIELD
# 4
Identifier1512196
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGATEWAY HEALTH PLAN
# 5
IdentifierP00267349
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: