Provider Demographics
NPI:1225013485
Name:PITTENGER, BASIL (MD)
Entity Type:Individual
Prefix:DR
First Name:BASIL
Middle Name:
Last Name:PITTENGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4528
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4528
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25030207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherNBMC GROUP NPI NUMBER
ORCB3544OtherRR MEDICARE GROUP NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR275268Medicaid
ORP00143347OtherRR MEDICARE PTAN NUMBER
OR275268Medicaid
ORI04428Medicare UPIN
OR275268Medicaid
OR0577260001Medicare NSC