Provider Demographics
NPI:1366475287
Name:WILLIS, ALLIRIC I (MD)
Entity type:Individual
Prefix:
First Name:ALLIRIC
Middle Name:I
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1100 WALNUT ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5563
Mailing Address - Country:US
Mailing Address - Phone:215-955-6750
Mailing Address - Fax:215-823-8222
Practice Address - Street 1:1100 WALNUT ST
Practice Address - Street 2:SUITE 500
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5563
Practice Address - Country:US
Practice Address - Phone:215-955-6750
Practice Address - Fax:215-823-8222
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4244632086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00385401OtherRAILROAD MEDICARE
PA1621481OtherPERSONAL CHOICE
PA2298641000OtherKEYSTONE IBC
PA1621481OtherHIGHMARK BLUE SHIELD
PA30032812OtherKEYSTONE MERCY
PA1016680610001Medicaid
PA1016680610004Medicaid
PA35488OtherHEALTH PARTNERS
PA5810126OtherAETNA HMO
PA2298641000OtherKEYSTONE IBC
PA30032812OtherKEYSTONE MERCY