Basic Information
| Provider Information | |||||||||
| NPI: | 1629062690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 ARCH ST | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302535335 | ||||||||
| FaxNumber: | 3302536233 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 ARCH ST | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302535335 | ||||||||
| FaxNumber: | 3302536233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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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 | 208600000X | 35036436 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | WI0420562 | 01 | OH | MEDICARE ID | OTHER | 0312861 | 05 | OH | MEDICAID |