Provider Demographics
NPI:1104887819
Name:WILLIS, RUDOLPH (MD)
Entity type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 KROTIK PL
Mailing Address - Street 2:IRVINGTON EMERGENT CARE AND REHABILITATION CENTER INC.
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-1708
Mailing Address - Country:US
Mailing Address - Phone:973-373-3000
Mailing Address - Fax:
Practice Address - Street 1:12 KROTIK PL
Practice Address - Street 2:IRVINGTON EMERGENT CARE AND REHABILITATION CENTER INC.
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-1708
Practice Address - Country:US
Practice Address - Phone:973-373-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA42750174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0887307Medicaid
NJ526391Medicare ID - Type Unspecified
NJ0887307Medicaid