Basic Information
| Provider Information | |||||||||
| NPI: | 1801981451 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLOUGHBY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 HIGHWAY 12 | ||||||||
| Address2: | |||||||||
| City: | HETTINGER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586397533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015676130 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 HIGHWAY 12 | ||||||||
| Address2: | |||||||||
| City: | HETTINGER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015674561 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
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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 | 207R00000X | 5103 | ND | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 123993 | 01 | ND | WORKER'S COMP | OTHER | 7776070 | 05 | SD | MEDICAID | 14656 | 05 | ND | MEDICAID | 3018140 | 05 | WA | MEDICAID | 7088230-00 | 05 | MN | MEDICAID | 25451 | 01 | SIOUX VALLEY | OTHER | 0568253 | 05 | IA | MEDICAID | 10781 | 01 | ND BLUE CROSS/BLUE SHIELD | OTHER | 45034068812 | 05 | NE | MEDICAID |