MEDICARE: ROBERT JOHN PETTIT MD

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	M6067	ID

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000010005951	OTHER	ID	BLUE SHIELD
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	10678	OTHER	ID	BLUE CROSS

NPI Number	:	1518071174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT JOHN PETTIT MD

Provider Business Mailing Address
First Line	:	3430 WASHINGTON PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7579
Country	:	US
Telephone Number	:	208-523-3060
Fax Number	:	208-523-0028

Provider Business Practice Location Address
First Line	:	3430 WASHINGTON PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7579
Country	:	US
Telephone Number	:	208-523-3060
Fax Number	:	208-523-0028

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	09/10/2009

2500 E 52ND ST N , CIGNA MEDICARE SERVICES
SIOUX FALLS, SD
57104-7106

Practice Phone: 605-373-0100
Practice Fax: