Basic Information
| Provider Information | |||||||||
| NPI: | 1871767145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PITA | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 N BAYOU ST | ||||||||
| Address2: | 7 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366035827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516908894 | ||||||||
| FaxNumber: | 2515442188 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 N BAYOU ST | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366035827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516908894 | ||||||||
| FaxNumber: | 2515442188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 12/13/2010 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208D00000X | 30547 | AL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 630000013 | 05 | AL | MEDICAID | 011846 | 01 | AL | MEDICARE GROUP NUMBER | OTHER | 1063439065 | 01 | AL | SITE NPI GROUP PAYEE NUMBER | OTHER |