MEDICARE: DR. MICHAEL LEE ETTNER 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	207P00000X	Emergency Medicine Physician	M-6577	ID
2	207P00000X	Emergency Medicine Physician	MD61241262	WA

General Provider Information

NPI Number	:	1629061940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL LEE ETTNER MD

Provider Business Mailing Address
First Line	:	229 S 7TH ST
Second Line	:
City	:	SAINT MARIES
State	:	ID
Zip	:	83861-1803
Country	:	US
Telephone Number	:	208-245-5551
Fax Number	:	208-245-5246

Provider Business Practice Location Address
First Line	:	229 S 7TH ST
Second Line	:
City	:	SAINT MARIES
State	:	ID
Zip	:	83861-1803
Country	:	US
Telephone Number	:	208-245-5551
Fax Number	:	208-245-5246

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

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	11/15/2023

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