Healthcare Provider Details

I. General information

NPI: 1467411314
Provider Name (Legal Business Name): INTERNAL MEDICINE & PEDIATRIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6433 CENTRALIA RD
CHESTERFIELD VA
23832-6556
US

IV. Provider business mailing address

6433 CENTRALIA RD
CHESTERFIELD VA
23832-6556
US

V. Phone/Fax

Practice location:
  • Phone: 804-425-3627
  • Fax: 804-425-7679
Mailing address:
  • Phone: 804-425-3627
  • Fax: 804-425-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DARREN S WITTE
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 804-425-3627