NPIMap

Individual provider Active NPI

Nicholas Willis, MD

  • Cardiovascular Disease Physician
  • Pine Bluff, AR
National Provider Identifier
1629292883
Registry record updated Oct 19, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Cardiovascular Disease PhysicianTaxonomy code 207RC0000X
License
E5292 Issued in AR
Practice address
1601 W 40TH Ave
Suite 301
Pine Bluff, AR 71603-6319
Phone
(870) 541-4285
Fax
(870) 541-4297
NPI assigned
Apr 12, 2007
Last updated
Oct 19, 2020By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 19, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Cardiovascular Disease Physician 207RC0000X E5292 AR Primary

Addresses

Primary practice location

1601 W 40TH Ave
Suite 301
Pine Bluff, AR 71603-6319

Mailing address

1601 W 40TH Ave
Suite 301
Pine Bluff, AR 71603-6319
Phone (870) 541-4285

Other identifiers 1

IdentifierTypeStateIssuer
168857001MedicaidAR

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address nicholaswillis@jrmc.allscriptsdirect.net

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080930000671 AR Practitioner - Interventional CardiologyPractitioner - Cardiovascular Disease (Cardiology)Practitioner - Internal MedicinePractitioner - Emergency Medicine 2668545294 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Interventional CardiologyAlso: Cardiovascular Disease (Cardiology), Internal Medicine
Education
University of Arkansas College of Medicine, 2005
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Jefferson Hospital Association, IncGroup PAC ID 8123927431, shared by 9 NPIs, 80 clinicians

Practice addresses (Care Compare)

1015 Unity Rd
Crossett, AR 71635-9443
Phone (870) 541-4285

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Coronary angioplasty and stenting21
Pacemaker insertion or repair14
Leg revascularization (restoring blood flow)1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
E5292ARMDCardiovascular Disease Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Jefferson Hospital Association, Inc Cardiovascular Disease CurrentSince Aug 1, 2012 Accepting new patients
Jefferson Hospital Association, Inc CurrentSince Jul 22, 2012 Accepting new patients
Jefferson Hospital Association Inc CurrentSince Jul 22, 2012 Accepting new patients
Jefferson Hospital Association, Inc Cardiovascular Disease Current Accepting new patients
Jefferson Hospital Assn, Inc. CurrentSince Dec 11, 2021 Accepting new patients
Tyler Emergency Physicians Past Accepting new patients

Locations

1015 Unity Rd
Crossett, AR 71635
Phone (870) 364-0590

1600 W 40th Ave
Pine Bluff, AR 71603
Phone (870) 541-7100

1601 W 40th Ave
Ste 301
Pine Bluff, AR 71603
Phone (870) 541-4285

1609 W 40th Ave
Ste 403
Pine Bluff, AR 71603
Phone (870) 534-4188

Interoperability endpoints

  • Direct secure messaging: nicholaswillis@jrmc.allscriptsdirect.net

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176336000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1603065600000",
    "number": "1629292883",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1601 W 40TH AVE",
            "address_2": "SUITE 301",
            "city": "PINE BLUFF",
            "state": "AR",
            "postal_code": "716036319",
            "telephone_number": "870-541-4285",
            "fax_number": "870-541-4297"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1601 W 40TH AVE",
            "address_2": "SUITE 301",
            "city": "PINE BLUFF",
            "state": "AR",
            "postal_code": "716036319",
            "telephone_number": "870-541-4285",
            "fax_number": "870-541-4297"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILLIS",
        "first_name": "NICHOLAS",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-04-12",
        "last_updated": "2020-10-19",
        "certification_date": "2020-10-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": "AR",
            "license": "E5292",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "168857001",
            "state": "AR"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "nicholaswillis@jrmc.allscriptsdirect.net",
            "affiliation": "N",
            "address_1": "1601 W 40th Ave",
            "address_2": "Suite 301",
            "city": "Pine Bluff",
            "state": "AR",
            "country_code": "US",
            "postal_code": "716036319",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Pine Bluff, AR

Sources for this page

Verify at the official NPI Registry.