Provider Demographics
NPI:1477580074
Name:PITTS, BRUCE G (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:G
Last Name:PITTS
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 1:801 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3641
Mailing Address - Country:US
Mailing Address - Phone:701-234-6707
Mailing Address - Fax:701-234-6979
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-6707
Practice Address - Fax:701-234-6979
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4232207R00000X
MN24715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN605793400Medicaid
ND14004Medicaid
MN605793400Medicaid
NDN899Medicare ID - Type Unspecified