NPIMap

Individual provider Active NPI

Mallory Renee Wittig, FNP

  • Family Nurse Practitioner
  • Metropolis, IL
National Provider Identifier
1114285517
Registry record updated May 9, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
209009469 Issued in IL
Practice address
12 Hospital Dr
Metropolis, IL 62960-2461
Phone
(618) 524-2182
Fax
(618) 524-2451
NPI assigned
Apr 24, 2012
Last updated
May 9, 2018By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 9, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X 209009469 IL Primary

Addresses

Primary practice location

12 Hospital Dr
Metropolis, IL 62960-2461

Mailing address

12 Hospital Dr
Metropolis, IL 62960-2461
Phone (618) 524-2182

Other practice location 1

28 Chick St
Metropolis, IL 62960-2467
Phone (618) 524-2176

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20121029000755 IL Practitioner - Nurse Practitioner 3870743883 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2011
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Massac Memorial HospitalGroup PAC ID 3072422799, 15 clinicians

Practice addresses (Care Compare)

1204 W 10TH St
Suite C
Metropolis, IL 62960-2482
Phone (618) 524-8224

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

Practice roles

OrganizationSpecialtyStatusNew patients
Massac Memorial Hospital CurrentSince Apr 16, 2018 Accepting new patients
Massac Memorial Hospital CurrentSince Apr 16, 2018 Accepting new patients
Massac Memorial Hospital Current Accepting new patients
Massac Memorial Hospital Past Accepting new patients
Massac Memorial Hospital Past Accepting new patients
Southern Illinois Pain Management PastSince May 8, 2018 Accepting new patients

Locations

1204 W 10th St
Ste A
Metropolis, IL 62960
Phone (618) 524-3572

1204 W 10th St
Ste C
Metropolis, IL 62960
Phone (618) 524-2182

28 Chick St
Metropolis, IL 62960
Phone (618) 427-2680

28 Chick St
Ste 100
Metropolis, IL 62960
Phone (618) 524-8381

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1335225600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1525824000000",
    "number": "1114285517",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12 HOSPITAL DR",
            "city": "METROPOLIS",
            "state": "IL",
            "postal_code": "629602461",
            "telephone_number": "618-524-2182",
            "fax_number": "618-524-2451"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12 HOSPITAL DR",
            "city": "METROPOLIS",
            "state": "IL",
            "postal_code": "629602461",
            "telephone_number": "618-524-2182",
            "fax_number": "618-524-2451"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "28 Chick St",
            "address_purpose": "LOCATION",
            "city": "Metropolis",
            "state": "IL",
            "postal_code": "629602467",
            "country_code": "US",
            "telephone_number": "618-524-2176",
            "fax_number": "618-524-4131",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WITTIG",
        "first_name": "MALLORY",
        "middle_name": "RENEE",
        "credential": "FNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-04-24",
        "last_updated": "2018-05-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "IL",
            "license": "209009469",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Metropolis, IL

Sources for this page

Verify at the official NPI Registry.