Basic Information
| Provider Information | |||||||||
| NPI: | 1376722108 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLIAMS CLINIC, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3409 UNION BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631151127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142614834 | ||||||||
| FaxNumber: | 3143833970 | ||||||||
| Practice Location | |||||||||
| Address1: | 3409 UNION BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631151127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142614834 | ||||||||
| FaxNumber: | 3143833970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 09/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | ROY | ||||||||
| AuthorizedOfficialMiddleName: | JEROME | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3142614834 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R9968 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201722501 | 05 | MO | MEDICAID |