Basic Information
| Provider Information | |||||||||
| NPI: | 1073655585 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS-WUCH | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3810 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648033810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173474000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3415 MCINTOSH CIR | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173474000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | DR-51351 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 37638 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 2006020988 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | P01473386 | 01 | SC | RR MEDICARE | OTHER | 376382 | 05 | SC | MEDICAID |