MEDICARE: EDWARD R WILLIS JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	41094	TN
2	207Y00000X	Otolaryngology Physician	10751	MS

General Provider Information

NPI Number	:	1497794259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD R WILLIS JR. MD

Provider Business Mailing Address
First Line	:	PO BOX 2697
Second Line	:
City	:	BAY ST LOUIS
State	:	MS
Zip	:	39521-2697
Country	:	US
Telephone Number	:	228-467-5121
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 DRINKWATER RD
Second Line	:
City	:	BAY ST LOUIS
State	:	MS
Zip	:	39520-1614
Country	:	US
Telephone Number	:	228-467-5121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	05/30/2019

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Directions to “ EDWARD R WILLIS JR. MD” Practice Location

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