Provider Demographics
NPI:1669710638
Name:WILLSIE, PHILIP S (DO)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:S
Last Name:WILLSIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:151 FRIES MILL RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2016
Mailing Address - Country:US
Mailing Address - Phone:856-513-4124
Mailing Address - Fax:856-302-5932
Practice Address - Street 1:435 HURFFVILLE CROSS KEYS RD
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-2453
Practice Address - Country:US
Practice Address - Phone:856-513-4124
Practice Address - Fax:856-302-5932
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB09655000207RP1001X, 207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0466557Medicaid
NJ0466557Medicaid