Provider Demographics
NPI:1568141604
Name:WILLIS, RAHEEM
Entity Type:Individual
Prefix:
First Name:RAHEEM
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9830 REISTERSTOWN RD APT 534
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4394
Mailing Address - Country:US
Mailing Address - Phone:443-713-8911
Mailing Address - Fax:
Practice Address - Street 1:9830 REISTERSTOWN RD APT 534
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4394
Practice Address - Country:US
Practice Address - Phone:443-713-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10274106657344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi