Provider Demographics
NPI:1215038534
Name:PITTMAN, SHANNON DIONE (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DIONE
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4999
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4999
Mailing Address - Country:US
Mailing Address - Phone:601-984-5410
Mailing Address - Fax:601-815-3771
Practice Address - Street 1:1815 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3425
Practice Address - Country:US
Practice Address - Phone:601-815-5700
Practice Address - Fax:601-346-5708
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18628207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00249267OtherRAILROAD
LA1334952Medicaid
MSP00462304OtherRAILROAD MEDICARE
MS01273350Medicaid
MSI19164Medicare UPIN
MS01273350Medicaid
MS080004044Medicare PIN
LA1334952Medicaid