Healthcare Provider Details

I. General information

NPI: 1811057003
Provider Name (Legal Business Name): BRUCE A PETITT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 FAIRFAX PARK SUITE C
TUSCALOOSA AL
35406-2806
US

IV. Provider business mailing address

1060 FAIRFAX PARK SUITE C
TUSCALOOSA AL
35406-2806
US

V. Phone/Fax

Practice location:
  • Phone: 205-752-7337
  • Fax: 205-752-8013
Mailing address:
  • Phone: 205-752-7337
  • Fax: 205-752-8013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15378
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: