Healthcare Provider Details

I. General information

NPI: 1962068387
Provider Name (Legal Business Name): GEOFFREY ELLIS PITTMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W MASSEY RD
MEMPHIS TN
38120-4206
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 315
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 901-685-8245
  • Fax: 901-685-8248
Mailing address:
  • Phone: 901-227-7015
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number82646
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: