Basic Information
Provider Information | |||||||||
NPI: | 1881884997 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PITTMAN | ||||||||
FirstName: | ROCKY | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | OAKWOOD HOSPITAL & MEDICAL CENTER | ||||||||
Address2: | 18101 OAKWOOD BLVD | ||||||||
City: | DEARBORN | ||||||||
State: | MI | ||||||||
PostalCode: | 48124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143593700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5100 W BROAD ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432281607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6145442058 | ||||||||
FaxNumber: | 6145442444 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2007 | ||||||||
LastUpdateDate: | 02/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35096242 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 35096242 | OH | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 4301090770 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3120385 | 05 | OH |   | MEDICAID |