Healthcare Provider Details

I. General information

NPI: 1710951454
Provider Name (Legal Business Name): BRANDON KEITH WILLS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL STREET EMERGENCY MEDICINE
RICHMOND VA
23298-0401
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23298-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-4780
  • Fax: 804-828-4686
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-108855
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number0102202389
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: