Provider Demographics
NPI:1649443607
Name:WILLIS, AMBER D (MD)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:D
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:W
Other - Last Name:HALLMARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7326
Practice Address - Country:US
Practice Address - Phone:843-212-8070
Practice Address - Fax:843-212-8071
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAML002812207P00000X
SC40153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine