Provider Demographics
NPI:1104835180
Name:WILLIS, PAUL M (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:INGOMAR
Mailing Address - State:PA
Mailing Address - Zip Code:15127-0240
Mailing Address - Country:US
Mailing Address - Phone:412-771-2266
Mailing Address - Fax:412-771-2443
Practice Address - Street 1:27 HECKEL RD
Practice Address - Street 2:SUITE 213
Practice Address - City:MC KEES ROCKS
Practice Address - State:PA
Practice Address - Zip Code:15136-1616
Practice Address - Country:US
Practice Address - Phone:412-771-2266
Practice Address - Fax:412-771-2443
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070567L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018020950001Medicaid
PA359754OtherHIGHMARK BLUE SHIELD
PA0109675000OtherINDEPENDENCE BLUE SHIELD
PA1512196OtherGATEWAY HEALTH PLAN
PAP00267349OtherRAILROAD MEDICARE
PA1512196OtherGATEWAY HEALTH PLAN
PAH17005Medicare UPIN