Basic Information
| Provider Information | |||||||||
| NPI: | 1902007453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLOUGHBY | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229069007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342951000 | ||||||||
| FaxNumber: | 4349724266 | ||||||||
| Practice Location | |||||||||
| Address1: | LEE ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229080001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349242361 | ||||||||
| FaxNumber: | 4349242877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 07/29/2011 | ||||||||
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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 | 207P00000X | 0101245842 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 57010630 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 4301097903 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1902007453 | 05 | MI | MEDICAID |