Provider Demographics
NPI:1306840871
Name:WILLIAM R. FELLOWS, MD
Entity Type:Organization
Organization Name:WILLIAM R. FELLOWS, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:FELLOWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-388-7770
Mailing Address - Street 1:180 DEBUYS RD
Mailing Address - Street 2:STE 130
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4402
Mailing Address - Country:US
Mailing Address - Phone:228-388-7770
Mailing Address - Fax:
Practice Address - Street 1:180 DEBUYS RD
Practice Address - Street 2:STE 130
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4402
Practice Address - Country:US
Practice Address - Phone:228-388-7770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-11
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08239207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03109765Medicaid
MS512G700016Medicare PIN
MSDG9506Medicare PIN
MS03109765Medicaid