Basic Information
| Provider Information | |||||||||
| NPI: | 1134271570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITTE | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 STATE ST | ||||||||
| Address2: | MCCALL MEMORIAL HOSPITAL | ||||||||
| City: | MCCALL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836383704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086341776 | ||||||||
| FaxNumber: | 2086343873 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 FOREST ST | ||||||||
| Address2: | |||||||||
| City: | MCCALL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836385256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086341776 | ||||||||
| FaxNumber: | 2086343873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 08/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M8271 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000010147960 | 01 | BLUE CROSS OF IDAHO | OTHER | 806952300 | 05 | ID | MEDICAID |