1578581351 NPI number — DR. GAVIN T PITTMAN M.D.

Table of content: DR. GAVIN T PITTMAN M.D. (NPI 1578581351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578581351 NPI number — DR. GAVIN T PITTMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PITTMAN
Provider First Name:
GAVIN
Provider Middle Name:
T
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:
1578581351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 RADIO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-2619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-883-5375
Provider Business Mailing Address Fax Number:
651-254-1519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 JACKSON ST - MC 11503L
Provider Second Line Business Practice Location Address:
HEALTHPARTNERS REGIONSL SPECIALTY CLINICS
Provider Business Practice Location Address City Name:
ST. PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55101-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-254-2005
Provider Business Practice Location Address Fax Number:
651-254-1519
Provider Enumeration Date:
07/18/2006

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: 207X00000X , with the licence number:  47753 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 135135E949 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP52033 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 660273800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 969991044105 . This is a "PREFERREDONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 332G2PI . This is a "BLUECROSSBLUESHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 901999 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".




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