=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689746935
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENNIE C MCWILLIAMS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 02/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2211 LOMAS BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-272-2345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 BRADBURY DR SE STE 116
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-4310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-272-1476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0214X
-----------------------------------------------------
Taxonomy Name | Pediatric Pulmonology Physician
-----------------------------------------------------
License Number | F1812
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080P0214X
-----------------------------------------------------
Taxonomy Name | Pediatric Pulmonology Physician
-----------------------------------------------------
License Number | 81-90
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------