Healthcare Provider Details

I. General information

NPI: 1154489821
Provider Name (Legal Business Name): ALAN J A PITT MD P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 MILLENIUM WAY #100
MERIDIAN ID
83642-6439
US

IV. Provider business mailing address

1919 N 21ST ST
BOISE ID
83702-0736
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-3376
  • Fax:
Mailing address:
  • Phone: 208-331-3513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM7850
License Number StateID

VIII. Authorized Official

Name: DR. ALAN J PITT
Title or Position: OWNER
Credential: MD
Phone: 208-331-3513