Provider Demographics
NPI:1306153010
Name:KEITH WILLS
Entity type:Organization
Organization Name:KEITH WILLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-603-8583
Mailing Address - Street 1:661 ORANGEBURGH RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-6404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7600 RIVER RD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-6217
Practice Address - Country:US
Practice Address - Phone:201-845-5005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00243100282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital