Basic Information
| Provider Information | |||||||||
| NPI: | 1568451466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PITTARD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | CAMERON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 WARLEY ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295014444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436696694 | ||||||||
| FaxNumber: | 8436692500 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 WARLEY ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295014444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436696694 | ||||||||
| FaxNumber: | 8436692500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 12125 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 121255 | 05 | SC | MEDICAID |