Provider Demographics
NPI:1629147574
Name:PITTARD, JOSEPH MATT (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MATT
Last Name:PITTARD
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 1:2200 JEFFERSON AVE
Mailing Address - Street 2:5TH FLOOR MERCY PHO/CVO
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003
Practice Address - Country:US
Practice Address - Phone:270-441-4200
Practice Address - Fax:270-441-4249
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64245145Medicaid
KY0257907Medicare PIN
C74468Medicare UPIN
KYK219510Medicare PIN