Basic Information
| Provider Information | |||||||||
| NPI: | 1144317470 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOICE WILLIS CLINIC PA | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | BOICE-WILLIS CLINIC ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7200 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529370200 | ||||||||
| FaxNumber: | 2524510056 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 N WINSTEAD AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278048467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529370220 | ||||||||
| FaxNumber: | 2524511383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/07/2022 | ||||||||
| NPIReactivationDate: | 02/17/2022 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FAZIO | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2529370200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | 38821 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
No ID Information.