MEDICARE: DR. KANITTA CHAROENSIRI D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0102201672	VA

General Provider Information

NPI Number	:	1275596330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KANITTA CHAROENSIRI D.O.

Provider Business Mailing Address
First Line	:	3440 BELAIRE DR
Second Line	:
City	:	BLACKSBURG
State	:	VA
Zip	:	24060-8683
Country	:	US
Telephone Number	:	540-961-9395
Fax Number	:

Provider Business Practice Location Address
First Line	:	SCHIFFERT HEALTH CENTER
Second Line	:	213 MCCOMAS HALL
City	:	BLACKSBURG
State	:	VA
Zip	:	24061-0001
Country	:	US
Telephone Number	:	540-231-5313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	07/08/2007

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