Basic Information
| Provider Information | |||||||||
| NPI: | 1124092051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIDMER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977090670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413897741 | ||||||||
| FaxNumber: | 5412788375 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 NE MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413822811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD22936 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | MD22936 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | MD22936 | OR | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RI0011X | MD22936 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | P00083868 | 01 | OR | RAIL ROAD MEDICARE | OTHER | 150842 | 05 | OR | MEDICAID |