Provider Demographics
NPI:1811057003
Name:PETITT, BRUCE A (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:PETITT
Suffix:
Gender:M
Credentials:MD
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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
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2010-12-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AL15378208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051093844OtherBLUE CROSS/BLUE SHIELD OF AL
AL009921560Medicaid
AL051093844OtherBLUE CROSS/BLUE SHIELD OF AL