Basic Information
| Provider Information | |||||||||
| NPI: | 1679661912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLCOX | ||||||||
| FirstName: | LORRAINE | ||||||||
| MiddleName: | PUSSER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLCOX | ||||||||
| OtherFirstName: | JUNE | ||||||||
| OtherMiddleName: | LORRAINE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 10925 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379390925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657668800 | ||||||||
| FaxNumber: | 8654509374 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 PAMPLICO HWY | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295056019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436643301 | ||||||||
| FaxNumber: | 8436643723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25452 | SC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 254520 | 05 | SC | MEDICAID |