Provider Demographics
NPI:1194741124
Name:WILLS, MARION A (MD)
Entity type:Individual
Prefix:
First Name:MARION
Middle Name:A
Last Name:WILLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANDY
Other - Middle Name:
Other - Last Name:WILLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:450 OLD GREENVILLE HWY
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631
Practice Address - Country:US
Practice Address - Phone:864-653-8964
Practice Address - Fax:846-653-8963
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049597208000000X
SC52223208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC522232Medicaid
GA000919256DMedicaid
GA117546OtherPEACHSTATE MEDICAID
GA374160OtherWELLCARE MEDICAID
GA000919256AMedicaid
GA000919256EMedicaid
GA300035718AMedicaid
GA830853OtherBCBS GEORGIA