Provider Demographics
NPI:1518435452
Name:PETTIT PEDIATRICS LLC
Entity Type:Organization
Organization Name:PETTIT PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-299-0593
Mailing Address - Street 1:3431 W 500 N
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-9710
Mailing Address - Country:US
Mailing Address - Phone:435-781-8897
Mailing Address - Fax:
Practice Address - Street 1:1360 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-4203
Practice Address - Country:US
Practice Address - Phone:435-789-7337
Practice Address - Fax:435-789-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-08
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty