MEDICARE: KEITH ANDREW DERCO M.D.

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	208000000X	Pediatrics Physician	0101052086	VA

General Provider Information

NPI Number	:	1255424206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH ANDREW DERCO M.D.

Provider Business Mailing Address
First Line	:	11551 NUCKOLS RD
Second Line	:	SUITE F
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-5565
Country	:	US
Telephone Number	:	804-364-4400
Fax Number	:	804-364-0120

Provider Business Practice Location Address
First Line	:	11551 NUCKOLS RD
Second Line	:	SUITE F
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-5565
Country	:	US
Telephone Number	:	804-364-4400
Fax Number	:	804-364-0120

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	05/22/2008

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