=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699296764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYNN PITTMAN DO INTERNAL MEDICINE ENTERPRISE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3363 N PENNSYLVANIA ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46205-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-924-4545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3140 N WINDMILL CT
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47805-8627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-241-4749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. LYNN PITTMAN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 812-241-4749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 02002857A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------