Healthcare Provider Details

I. General information

NPI: 1295789733
Provider Name (Legal Business Name): MICHAEL L WILLOUGHBY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 CALHOUN ST
CHARLESTON SC
29401-1113
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-606-7810
  • Fax: 843-606-8088
Mailing address:
  • Phone: 843-789-1620
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number021612
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number39016
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: