Provider Demographics
NPI:1558311969
Name:WILLIAMS MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:WILLIAMS MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY-TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:MARCUS
Authorized Official - Last Name:WILMOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-595-6734
Mailing Address - Street 1:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92836-1039
Mailing Address - Country:US
Mailing Address - Phone:415-595-6734
Mailing Address - Fax:714-526-3110
Practice Address - Street 1:111 N TAYLOR AVE
Practice Address - Street 2:SUITE A
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-4358
Practice Address - Country:US
Practice Address - Phone:314-822-9997
Practice Address - Fax:314-822-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2657039-0208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215210Medicare PIN
MO000014075Medicare PIN
IL215209Medicare PIN