Provider Demographics
NPI:1669417820
Name:WILLARD, ELLEN M (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PAGE RD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8798
Mailing Address - Country:US
Mailing Address - Phone:910-295-5511
Mailing Address - Fax:
Practice Address - Street 1:220 PAGE RD
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374
Practice Address - Country:US
Practice Address - Phone:910-715-3500
Practice Address - Fax:910-715-3501
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34205207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC110081955OtherPALMETTO GBA PROVIDER#
NCFH1000340OtherFIRSTCAROLINACARE PROV.#
NC3600597OtherEVERCARE
SCN34205OtherSC MEDICAID PROVIDER#
NC80186OtherMEDCOST PROVIDER#
NC87634OtherBC/BS PROVIDER#
NC8987634Medicaid
C70521Medicare UPIN
NC8987634Medicaid