=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164661203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD LYNN WILLIAMS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2009
-----------------------------------------------------
Last Update Date | 06/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6631 WARD BLVD
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27893-5963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-236-1929
-----------------------------------------------------
Fax | 252-236-1929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2203 DARIEN PL NW
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27896-1583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-237-3483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Emergency Medicine) Physician
-----------------------------------------------------
License Number | 27649
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 27649
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------