1558590380 NPI number — WILLIAM O. WITT, M.D., PLLC

Table of content: (NPI 1558590380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558590380 NPI number — WILLIAM O. WITT, M.D., PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM O. WITT, M.D., PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558590380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3649 SOLUTIONS CENTER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-3006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-367-7246
Provider Business Mailing Address Fax Number:
859-254-5715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2050 VERSAILLES RD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40504-1405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-367-7246
Provider Business Practice Location Address Fax Number:
859-254-5715
Provider Enumeration Date:
07/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WITT
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
ORIN
Authorized Official Title or Position:
OWNER/REGISTERED AGENT
Authorized Official Telephone Number:
859-367-7246

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  19042 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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