Basic Information
| Provider Information | |||||||||
| NPI: | 1861621633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PITTMAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 DELNOR DR | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601344222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306680833 | ||||||||
| FaxNumber: | 6306677685 | ||||||||
| Practice Location | |||||||||
| Address1: | 4830 KNIGHTSBRIDGE BLVD | ||||||||
| Address2: | SUITE J | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432142300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142933230 | ||||||||
| FaxNumber: | 6142934030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
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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 | 208600000X | 125.055834 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 35123279 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 036138487 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0104249 | 05 | OK | MEDICAID | 206147 | 01 | IL | MEDICARE PTAN GROUP | OTHER | F400237729 | 01 | IL | MEDICARE PTAN INDIVIDUAL | OTHER |