Provider Demographics
NPI:1225033434
Name:WILLIS, ROBERT A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
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 1:1034 GOLF CLUB CIR W
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-8890
Mailing Address - Country:US
Mailing Address - Phone:615-347-7121
Mailing Address - Fax:
Practice Address - Street 1:800 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1658
Practice Address - Country:US
Practice Address - Phone:270-326-4800
Practice Address - Fax:270-326-4820
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD454555207Y00000X
SC86684207Y00000X
TNM00000018696207Y00000X
IL036158466207Y00000X
KY49641207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN81658OtherBCBS
A99671Medicare UPIN
KYK225850Medicare PIN