1144220641 NPI number — DR. KATHLEEN R WITTBERG MD

Table of content: DR. KATHLEEN R WITTBERG MD (NPI 1144220641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144220641 NPI number — DR. KATHLEEN R WITTBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITTBERG
Provider First Name:
KATHLEEN
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1144220641
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9000 NORTH MAIN ST
Provider Second Line Business Mailing Address:
SUITE 403 MAIN STREET FAMILY PRACTICE INC
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45415-1180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-836-1572
Provider Business Mailing Address Fax Number:
937-832-0728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9000 NORTH MAIN ST
Provider Second Line Business Practice Location Address:
MAIN STREET FAMILY PRACTICE INC SUITE 403
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45415-1180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-836-5171
Provider Business Practice Location Address Fax Number:
937-832-0728
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  35048051 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1139935 . This is a "CIGNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000013668 . This is a "ANTHEM DR WITTBERG" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4328348 . This is a "AETNA DR WITTBERG" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0534265 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0122424 . This is a "UHC DR WITTBERG" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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