Provider Demographics
NPI:1427296912
Name:MID-CITIES MEDICAL INSTITUTE, PLLC
Entity type:Organization
Organization Name:MID-CITIES MEDICAL INSTITUTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:817-498-7400
Mailing Address - Street 1:PO BOX 1583
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-1583
Mailing Address - Country:US
Mailing Address - Phone:817-498-7400
Mailing Address - Fax:817-503-9967
Practice Address - Street 1:8208 BEDFORD EULESS RD
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-7214
Practice Address - Country:US
Practice Address - Phone:817-498-7400
Practice Address - Fax:817-503-9967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC6911111NR0400X
TXJ0365207LP2900X
TXMCH-7354208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF83514Medicare UPIN
TX0A4660Medicare UPIN