1518917566 NPI number — HARLAN ERIC PETTIT M.D.

Table of content: HARLAN ERIC PETTIT M.D. (NPI 1518917566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518917566 NPI number — HARLAN ERIC PETTIT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTIT
Provider First Name:
HARLAN
Provider Middle Name:
ERIC
Provider Name Prefix Text:
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:
1518917566
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 PIRATES CV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARATHON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33050-2925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-743-0222
Provider Business Mailing Address Fax Number:
305-743-0114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3301 OVERSEAS HWY
Provider Second Line Business Practice Location Address:
FISHERMEN'S HOSPITAL ANESTHESIA DEPT
Provider Business Practice Location Address City Name:
MARATHON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33050-2329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-289-6407
Provider Business Practice Location Address Fax Number:
305-289-6417
Provider Enumeration Date:
05/11/2006

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: 207L00000X , with the licence number:  ME62372 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207LP2900X , with the licence number: ME62372 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 050084607 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 370761000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17803 . This is a "BLUE CROSS BLUE SHIELD FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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