Active NPI
Robert John Pettit, MD
- Pediatrics Physician
- Idaho Falls, ID
National Provider Identifier
1518071174
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- M6067
- Practice address
- 3430 Washington Pkwy
Idaho Falls, ID 83404-7579 - Phone
- (208) 523-3060
- Fax
- (208) 523-0028
- NPI assigned
- Aug 19, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | M6067 | ID | Primary |
Addresses
Primary practice location
3430 Washington Pkwy
Idaho Falls, ID 83404-7579
Mailing address
3430 Washington Pkwy
Idaho Falls, ID 83404-7579
Phone (208) 523-3060
Other identifiers 6
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0117419 | Medicaid | MT | |
| 114945800 | Medicaid | WY | |
| 000010005951 | Other | ID | BLUE SHIELD |
| 1285786046 | Medicaid | WY | |
| 002298200 | Medicaid | ID | |
| 10678 | Other | ID | BLUE CROSS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| M6067 | ID | MD | Pediatrics Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Medical Center for Children & Adolescents, PA | Pediatrics | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
dba The Pediatric Center
- Pediatrics Physician
- Idaho Falls, ID
- NPI 1073528998
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1155945600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1252540800000",
"number": "1518071174",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3430 WASHINGTON PKWY",
"city": "IDAHO FALLS",
"state": "ID",
"postal_code": "834047579",
"telephone_number": "208-523-3060",
"fax_number": "208-523-0028"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3430 WASHINGTON PKWY",
"city": "IDAHO FALLS",
"state": "ID",
"postal_code": "834047579",
"telephone_number": "208-523-3060",
"fax_number": "208-523-0028"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETTIT",
"first_name": "ROBERT",
"middle_name": "JOHN",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-19",
"last_updated": "2009-09-10",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "ID",
"license": "M6067",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0117419",
"state": "MT"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "114945800",
"state": "WY"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE SHIELD",
"identifier": "000010005951",
"state": "ID"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1285786046",
"state": "WY"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "002298200",
"state": "ID"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS",
"identifier": "10678",
"state": "ID"
}
],
"endpoints": [],
"other_names": []
}Other providers in Idaho Falls, ID
- Pettingill Counseling Services, PC
- Pettingill Counseling Services, Professional Corporation
- Pettingill Counseling Services, Professional Corporation
- Eric Vernon Pettingill, LCPC
- Tamara K. Pettingill, LCSW
- David Aaron Petty, D.O.
- Kayla Suann Petty
- Wendell E Petty, M.D.
- Douglas Frank Pfister, ASLD
- Pharmacy Care Consultants
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 10, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.