Provider Demographics
NPI:1689228868
Name:EDWARD R WILLIS JR, MD
Entity Type:Organization
Organization Name:EDWARD R WILLIS JR, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:228-467-5121
Mailing Address - Street 1:P.O. BOX 2697
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39521
Mailing Address - Country:US
Mailing Address - Phone:228-467-5121
Mailing Address - Fax:228-467-0208
Practice Address - Street 1:100 DRINKWATER RD
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520
Practice Address - Country:US
Practice Address - Phone:228-467-5121
Practice Address - Fax:228-467-0208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty