Provider Demographics
NPI:1124025085
Name:PETTITT, RAENA M (DO)
Entity Type:Individual
Prefix:DR
First Name:RAENA
Middle Name:M
Last Name:PETTITT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 WARDS RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2101
Mailing Address - Country:US
Mailing Address - Phone:434-582-2273
Mailing Address - Fax:434-582-1363
Practice Address - Street 1:2321 WARDS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2101
Practice Address - Country:US
Practice Address - Phone:434-582-2273
Practice Address - Fax:434-582-1363
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201453207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010215048Medicaid
203639329013OtherTRICARE PROVIDER NUMBER
010215048OtherVA PREMIER PROVIDER NUMBE
186414OtherANTHEM PROVIDER NUMBER
203639329OtherPCHP PROVIDER NUMBER
D5084OtherMEDCOST PROVIDER NUMBER
2379390OtherCIGNA PROVIDER NUMBER
78660OtherSENTARA/OPTIMA PROVIDER N
203639329OtherUNITED HEALTHCARE PROVIDE
329088OtherSOUTHERN HEALTH PROVIDER
VAI16523Medicare UPIN
VA010215048Medicaid
186414OtherANTHEM PROVIDER NUMBER