Basic Information
| Provider Information | |||||||||
| NPI: | 1356385991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | JEFF | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7609 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598077609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 0101059226 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 56022 | MT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 5825041 | 05 | VA | MEDICAID | 327082 | 01 | VA | ANTHEM | OTHER | 8905530 | 05 | NC | MEDICAID | 15750 | 01 | VA | OPTIMA | OTHER | 1659563799 | 01 | VA | GROUP NPI | OTHER | 100012482 | 01 | VA | MEDICARE RR | OTHER | 5426240 | 01 | VA | AETNA | OTHER |