Provider Demographics
NPI:1316268386
Name:CHARLES ROBERT PETTIT MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:CHARLES ROBERT PETTIT MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-843-3999
Mailing Address - Street 1:3906 HEATHFIELD PL
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-7627
Mailing Address - Country:US
Mailing Address - Phone:707-843-3999
Mailing Address - Fax:707-545-3999
Practice Address - Street 1:175 CONCOURSE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-8217
Practice Address - Country:US
Practice Address - Phone:707-284-9200
Practice Address - Fax:707-284-9204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A235594Medicare UPIN