=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184087959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAD WILLIS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2016
-----------------------------------------------------
Last Update Date | 08/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 2ND AVE STE C2
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42101-1791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-780-2780
-----------------------------------------------------
Fax | 270-780-2755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2697
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42102-7697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-745-1100
-----------------------------------------------------
Fax | 270-745-1156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 42665
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 56988
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207XX0004X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Foot and Ankle Surgery Physician
-----------------------------------------------------
License Number | 56988
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------