Provider Demographics
NPI:1114280831
Name:WITT, KAILEY (MD)
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:
Last Name:WITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CONEY ST W
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-2102
Mailing Address - Country:US
Mailing Address - Phone:218-347-1200
Mailing Address - Fax:
Practice Address - Street 1:1000 CONEY ST W
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2102
Practice Address - Country:US
Practice Address - Phone:218-347-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN59624207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400252144Medicare PIN