Basic Information
| Provider Information | |||||||||
| NPI: | 1346244787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BILLS | ||||||||
| FirstName: | PONCET | ||||||||
| MiddleName: | COURTLAND | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 449 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457500449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744500 | ||||||||
| FaxNumber: | 7403745887 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 5TH ST | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457158916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409842391 | ||||||||
| FaxNumber: | 7409848834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 11/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34004017 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000120136 | 01 | OH | ANTHEM | OTHER | 000000699797 | 01 | OH | ANTHEM | OTHER | 010063626 | 01 | OH | RRMCR | OTHER | 0971480 | 05 | OH | MEDICAID |