Provider Demographics
NPI:1376722108
Name:WILLIAMS CLINIC, LTD
Entity Type:Organization
Organization Name:WILLIAMS CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:314-261-4834
Mailing Address - Street 1:3409 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-1127
Mailing Address - Country:US
Mailing Address - Phone:314-261-4834
Mailing Address - Fax:314-383-3970
Practice Address - Street 1:3409 UNION BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-1127
Practice Address - Country:US
Practice Address - Phone:314-261-4834
Practice Address - Fax:314-383-3970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2011-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9968207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201722501Medicaid
MO201722501Medicaid