MEDICARE: EDWARD G. WITT D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	1742	TN
2	207Q00000X	Family Medicine Physician	DO-556	AL
3	207QA0401X	Addiction Medicine (Family Medicine) Physician	DO-556	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4120997	OTHER	TN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1841239654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD G. WITT D.O.

Provider Business Mailing Address
First Line	:	11220 S MEMORIAL PKWY
Second Line	:	SUITE A,B
City	:	HUNTSVILLE
State	:	AL
Zip	:	35803-4415
Country	:	US
Telephone Number	:	256-880-5818
Fax Number	:

Provider Business Practice Location Address
First Line	:	11220 MEMORIAL PKWY SW
Second Line	:	SUITE AB
City	:	HUNTSVILLE
State	:	AL
Zip	:	35803-4415
Country	:	US
Telephone Number	:	256-880-5818
Fax Number	:	256-883-5346

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	11/26/2012

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Directions to “ EDWARD G. WITT D.O.” Practice Location

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