Basic Information
| Provider Information | |||||||||
| NPI: | 1467407072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | JERROLD | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2153 DEPT 20002 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352870001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774650012 | ||||||||
| FaxNumber: | 3034381351 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 GOOD SAMARITAN WAY | ||||||||
| Address2: | RADIOLOGY DEPT | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628642402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182424600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 36057038 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300119485 | 01 | IL | RAILROAD ST JOES/UTLAH | OTHER | 300117217 | 01 | IL | RAILROAD GOOD SAM & ST MARY'S | OTHER | 036057038-3 | 05 | IL | MEDICAID |