Healthcare Provider Details

I. General information

NPI: 1033194386
Provider Name (Legal Business Name): DR. WIT INTERNAL MEDICINE PROF GERIATRIC CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5621 DELMAR BLVD #105
SAINT LOUIS MO
63112-2656
US

IV. Provider business mailing address

7137 MARYLAND AVE
SAINT LOUIS MO
63130-4417
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-2727
  • Fax: 314-367-2989
Mailing address:
  • Phone: 314-721-0675
  • Fax: 314-721-2830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. WIT A JAMRY
Title or Position: PRESIDENT
Credential: MD
Phone: 314-367-2727