=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063006195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIS MEDICAL VENTURES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2021
-----------------------------------------------------
Last Update Date | 03/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 SEAGRASS STATION RD
-----------------------------------------------------
City | BLUFFTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29910-9549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-836-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 LONG CREEK LN
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31324-8601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-235-3012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. SIMON WILLIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 571-235-3012
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------