1861621633 NPI number — DR. MATTHEW R PITTMAN M.D.

Table of content: DR. MATTHEW R PITTMAN M.D. (NPI 1861621633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861621633 NPI number — DR. MATTHEW R PITTMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PITTMAN
Provider First Name:
MATTHEW
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861621633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
351 DELNOR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GENEVA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60134-4222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-668-0833
Provider Business Mailing Address Fax Number:
630-667-7685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4830 KNIGHTSBRIDGE BLVD
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43214-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-293-3230
Provider Business Practice Location Address Fax Number:
614-293-4030
Provider Enumeration Date:
07/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  125.055834 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 35123279 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 036138487 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0104249 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 206147 . This is a "MEDICARE PTAN GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: F400237729 . This is a "MEDICARE PTAN INDIVIDUAL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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