Provider Demographics
NPI:1013077205
Name:BRUCE A PETITT M.D. P.C.
Entity Type:Organization
Organization Name:BRUCE A PETITT M.D. P.C.
Other - Org Name:WEST ALABAMA PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-752-7337
Mailing Address - Street 1:1060 FAIRFAX PARK
Mailing Address - Street 2:SUITE C
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2806
Mailing Address - Country:US
Mailing Address - Phone:205-752-7337
Mailing Address - Fax:205-752-8013
Practice Address - Street 1:1060 FAIRFAX PARK
Practice Address - Street 2:SUITE C
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2806
Practice Address - Country:US
Practice Address - Phone:205-752-7337
Practice Address - Fax:205-752-8013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL104775Medicaid