Provider Demographics
NPI:1467407072
Name:WILLIS, JERROLD C (MD)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:C
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 2153 DEPT 20002
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-0001
Mailing Address - Country:US
Mailing Address - Phone:877-465-0012
Mailing Address - Fax:303-438-1351
Practice Address - Street 1:1 GOOD SAMARITAN WAY
Practice Address - Street 2:RADIOLOGY DEPT
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2402
Practice Address - Country:US
Practice Address - Phone:618-242-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360570382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL300119485OtherRAILROAD ST JOES/UTLAH
IL300117217OtherRAILROAD GOOD SAM & ST MARY'S
IL036057038-3Medicaid
IL036057038-3Medicaid
ILL82546Medicare PIN
IL300117217OtherRAILROAD GOOD SAM & ST MARY'S