=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396369906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIS F GAFFNEY M.D. P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2020
-----------------------------------------------------
Last Update Date | 05/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2939 S SHERIDAN RD
-----------------------------------------------------
City | STANTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48888-9285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-831-9009
-----------------------------------------------------
Fax | 989-607-6875
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2939 S SHERIDAN RD
-----------------------------------------------------
City | STANTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48888-9285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-831-9009
-----------------------------------------------------
Fax | 989-607-6875
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | ALEXANDRINE BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 989-831-9009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------