Basic Information
Provider Information | |||||||||
NPI: | 1366475287 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIS | ||||||||
FirstName: | ALLIRIC | ||||||||
MiddleName: | I. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1100 WALNUT ST | ||||||||
Address2: | SUITE 500 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191075563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159556750 | ||||||||
FaxNumber: | 2158238222 | ||||||||
Practice Location | |||||||||
Address1: | 1100 WALNUT ST | ||||||||
Address2: | SUITE 500 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191075563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159556750 | ||||||||
FaxNumber: | 2158238222 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 08/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | MD424463 | PA | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | MD424463 | PA | N |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | P00385401 | 01 | PA | RAILROAD MEDICARE | OTHER | 1621481 | 01 | PA | PERSONAL CHOICE | OTHER | 2298641000 | 01 | PA | KEYSTONE IBC | OTHER | 1621481 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 30032812 | 01 | PA | KEYSTONE MERCY | OTHER | 1016680610001 | 05 | PA |   | MEDICAID | 1016680610004 | 05 | PA |   | MEDICAID | 35488 | 01 | PA | HEALTH PARTNERS | OTHER | 5810126 | 01 | PA | AETNA HMO | OTHER |