Provider Demographics
NPI:1699296764
Name:LYNN PITTMAN DO INTERNAL MEDICINE ENTERPRISE LLC
Entity type:Organization
Organization Name:LYNN PITTMAN DO INTERNAL MEDICINE ENTERPRISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-241-4749
Mailing Address - Street 1:3140 N WINDMILL CT
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47805-8627
Mailing Address - Country:US
Mailing Address - Phone:812-241-4749
Mailing Address - Fax:
Practice Address - Street 1:3363 N PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-3415
Practice Address - Country:US
Practice Address - Phone:317-924-4545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002857A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200521340Medicaid