Basic Information
| Provider Information | |||||||||
| NPI: | 1609888312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLE | ||||||||
| FirstName: | MARIANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7035 ST. ANDREWS ROAD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033586160 | ||||||||
| FaxNumber: | 8034074101 | ||||||||
| Practice Location | |||||||||
| Address1: | 7035 ST. ANDREWS ROAD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033586160 | ||||||||
| FaxNumber: | 8034074101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 06/03/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 628 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 006282 | 05 | SC | MEDICAID |