MEDICARE: JEFFREY A WIRTHLIN MD

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	2084P0800X	Psychiatry Physician	4301076448	MI

General Provider Information

NPI Number	:	1487664603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY A WIRTHLIN MD

Provider Business Mailing Address
First Line	:	1121 NORTH DRURY CT
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019
Country	:	US
Telephone Number	:	509-926-2668
Fax Number	:	509-926-2668

Provider Business Practice Location Address
First Line	:	2310 N MOLTER RD STE 105
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-8621
Country	:	US
Telephone Number	:	509-891-7867
Fax Number	:	509-922-0984

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	02/17/2011

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