Provider Demographics
NPI:1154534972
Name:WILLIE B LOUIS MD PA
Entity type:Organization
Organization Name:WILLIE B LOUIS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:LOUIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-534-2270
Mailing Address - Street 1:1102 SUMMERS AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4922
Mailing Address - Country:US
Mailing Address - Phone:803-534-2270
Mailing Address - Fax:803-534-2271
Practice Address - Street 1:1102 SUMMERS AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4922
Practice Address - Country:US
Practice Address - Phone:803-534-2270
Practice Address - Fax:803-534-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4128Medicaid
SCD90719Medicare UPIN
SC8212Medicare PIN