Basic Information
| Provider Information | |||||||||
| NPI: | 1003801499 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BITZER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 904 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175402350 | ||||||||
| FaxNumber: | 2173472323 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175402350 | ||||||||
| FaxNumber: | 2173472323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 02/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 036081888 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 036081888 | 05 | IL | MEDICAID |