Provider Demographics
NPI:1841239654
Name:WITT, EDWARD G (DO)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:G
Last Name:WITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11220 S MEMORIAL PKWY
Mailing Address - Street 2:SUITE A,B
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35803-4415
Mailing Address - Country:US
Mailing Address - Phone:256-880-5818
Mailing Address - Fax:
Practice Address - Street 1:11220 MEMORIAL PKWY SW
Practice Address - Street 2:SUITE AB
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35803-4415
Practice Address - Country:US
Practice Address - Phone:256-880-5818
Practice Address - Fax:256-883-5346
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1742207P00000X
ALDO-556207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4120997OtherBLUE CROSS BLUE SHIELD
G90750Medicare UPIN
TN3337693Medicare ID - Type Unspecified