Basic Information
| Provider Information | |||||||||
| NPI: | 1548253172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 N STREET EXT | ||||||||
| Address2: | |||||||||
| City: | HYANNIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026013825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087758282 | ||||||||
| FaxNumber: | 5087711496 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 N STREET EXT | ||||||||
| Address2: | |||||||||
| City: | HYANNIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026013825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087758282 | ||||||||
| FaxNumber: | 5087711496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 160529 | MA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9773983 | 05 | MA | MEDICAID | 2431064 | 01 | AETNA | OTHER | 160529 | 01 | TUFTS | OTHER | 5061233001 | 01 | CIGNA | OTHER | J21143 | 01 | BCBS | OTHER | 0900676 | 01 | UNITED HEALTH | OTHER | 2065118 | 05 | MA | MEDICAID | 68934 | 01 | PILGRIM | OTHER |