Provider Demographics
NPI:1326047341
Name:PITTS, PHILIP W (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:W
Last Name:PITTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S 42ND ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-2001
Mailing Address - Country:US
Mailing Address - Phone:479-273-9173
Mailing Address - Fax:479-464-9989
Practice Address - Street 1:2000 S 42ND ST STE 100
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-2001
Practice Address - Country:US
Practice Address - Phone:479-273-9173
Practice Address - Fax:479-464-9989
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2024-08-09
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
ARE-17303207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110235123OtherRAILROAD MEDICARE PIN
TXJ2901OtherTX LICENSE #
TX039011404Medicaid
110235123OtherRAILROAD MEDICARE PIN
8760B0Medicare PIN
TX039011404Medicaid