MEDICARE: SAMUEL M 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	207RG0100X	Gastroenterology Physician	12083	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P01077735	OTHER	SC	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770586588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL M WILLIS JR. MD

Provider Business Mailing Address
First Line	:	PO BOX 402145
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-2145
Country	:	US
Telephone Number	:	803-296-3502
Fax Number	:	803-296-7330

Provider Business Practice Location Address
First Line	:	2739 LAUREL ST
Second Line	:	1-A
City	:	COLUMBIA
State	:	SC
Zip	:	29204-2028
Country	:	US
Telephone Number	:	803-799-4800
Fax Number	:	803-256-0397

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	10/16/2012

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