MEDICARE: WITTENBORN PLASTIC SURGERY LLC

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	208200000X	Plastic Surgery Physician	87881	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71645X	OTHER	FL	MEDICARE

General Provider Information

NPI Number	:	1639333115
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WITTENBORN PLASTIC SURGERY LLC

Provider Business Mailing Address
First Line	:	13300 S CLEVELAND AVE STE 56
Second Line	:	#261
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3871
Country	:	US
Telephone Number	:	239-561-2313
Fax Number	:	888-500-2420

Provider Business Practice Location Address
First Line	:	14131 METROPOLIS AVE STE 105
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4332
Country	:	US
Telephone Number	:	239-561-2313
Fax Number	:	888-500-2420

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM SCOTT WITTENBORN
Credential	:	M.D.
Telephone Number	:	239-561-2313

Provider Enumeration Date	:	07/15/2008
Last Update Date	:	05/06/2009

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