Provider Demographics
NPI:1528054293
Name:WILLIS, MARSHALL RAY (MD)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:RAY
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:195 MYERS AVE
Mailing Address - City:GUILD
Mailing Address - State:TN
Mailing Address - Zip Code:37340-0128
Mailing Address - Country:US
Mailing Address - Phone:423-942-1674
Mailing Address - Fax:423-942-9982
Practice Address - Street 1:1000 HIGHWAY 28
Practice Address - Street 2:GRANDVIEW MEDICAL CENTER
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3638
Practice Address - Country:US
Practice Address - Phone:423-942-1674
Practice Address - Fax:423-942-9982
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN0113772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3808477Medicaid
G46002Medicare UPIN
TN3808477Medicare ID - Type Unspecified