Basic Information
| Provider Information | |||||||||
| NPI: | 1821183542 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLES | ||||||||
| FirstName: | STUART | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 FAIRMOUNT AVENUE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104947921 | ||||||||
| FaxNumber: | 4109028247 | ||||||||
| Practice Location | |||||||||
| Address1: | 9103 FRANKLIN SQUARE DR | ||||||||
| Address2: | 300 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212373900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106825282 | ||||||||
| FaxNumber: | 4106825286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 06/25/2017 | ||||||||
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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 | 207RC0200X | D0036663 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | D0036663 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 345806 | 01 | MAMSI | OTHER | 290008363 | 01 | RAILROAD MEDICARE | OTHER | 4800203 | 01 | UNITED HEALTHCARE MCO | OTHER | 42428624 420A | 01 | MD | BLUE SHIELD | OTHER | 0009 E554 | 01 | MD | BLUE CHOICE/FEP | OTHER | 1427796 | 01 | UNITED HEALTHCARE | OTHER | 533281800 | 05 | MD | MEDICAID |