1033194386 NPI number — DR. WIT INTERNAL MEDICINE PROF GERIATRIC CARE

Table of content: (NPI 1033194386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033194386 NPI number — DR. WIT INTERNAL MEDICINE PROF GERIATRIC CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. WIT INTERNAL MEDICINE PROF GERIATRIC CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033194386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7137 MARYLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63130-4417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-721-0675
Provider Business Mailing Address Fax Number:
314-721-2830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5621 DELMAR BLVD
Provider Second Line Business Practice Location Address:
#105
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63112-2656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-367-2727
Provider Business Practice Location Address Fax Number:
314-367-2989
Provider Enumeration Date:
12/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JAMRY
Authorized Official First Name:
WIT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-367-2727

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LG0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 505084103 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: CG9649 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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