Provider Demographics
NPI:1467411314
Name:INTERNAL MEDICINE & PEDIATRIC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE & PEDIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WITTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-425-3627
Mailing Address - Street 1:6433 CENTRALIA RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-6556
Mailing Address - Country:US
Mailing Address - Phone:804-425-3627
Mailing Address - Fax:804-425-7679
Practice Address - Street 1:6433 CENTRALIA RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6556
Practice Address - Country:US
Practice Address - Phone:804-425-3627
Practice Address - Fax:804-425-7679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C09390Medicare ID - Type UnspecifiedGROUP #