Provider Demographics
NPI:1811235591
Name:WILLIS F GAFFNEY M.D. P.C.
Entity Type:Organization
Organization Name:WILLIS F GAFFNEY M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:FAYNE
Authorized Official - Last Name:GAFFNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:989-831-9009
Mailing Address - Street 1:2939 S SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48888-9285
Mailing Address - Country:US
Mailing Address - Phone:989-831-9009
Mailing Address - Fax:989-831-9150
Practice Address - Street 1:2939 S SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:MI
Practice Address - Zip Code:48888-9285
Practice Address - Country:US
Practice Address - Phone:989-831-9009
Practice Address - Fax:989-831-9150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050158207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2729900Medicaid
MI2729900Medicaid
MI0590034Medicare PIN