Healthcare Provider Details

I. General information

NPI: 1902048226
Provider Name (Legal Business Name): RYAN C PETTIT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1958 AL HIGHWAY 157
CULLMAN AL
35058-0609
US

IV. Provider business mailing address

PO BOX 2895
CULLMAN AL
35056-2895
US

V. Phone/Fax

Practice location:
  • Phone: 256-737-2090
  • Fax: 256-737-2091
Mailing address:
  • Phone: 256-735-5071
  • Fax: 256-801-7626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.31240
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31240
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: