Healthcare Provider Details

I. General information

NPI: 1194741124
Provider Name (Legal Business Name): MARION A WILLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ANDY WILLS M.D.

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 OLD GREENVILLE HWY
CLEMSON SC
29631
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-653-8964
  • Fax: 846-653-8963
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number049597
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number52223
License Number StateSC

VII. Legacy identifiers

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

# 1
Identifier522232
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 2
Identifier000919256D
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 3
Identifier117546
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerPEACHSTATE MEDICAID
# 4
Identifier374160
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerWELLCARE MEDICAID
# 5
Identifier000919256A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 6
Identifier000919256E
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 7
Identifier300035718A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 8
Identifier830853
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerBCBS GEORGIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: