Basic Information
| Provider Information | |||||||||
| NPI: | 1316900749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTIT | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | JARRETT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2345 CHESTERFIELD AVE | ||||||||
| Address2: | STE 302 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043439923 | ||||||||
| FaxNumber: | 3043439925 | ||||||||
| Practice Location | |||||||||
| Address1: | 2930 CHESTERFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043439923 | ||||||||
| FaxNumber: | 3043439925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 15412 | WV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0071519000 | 05 | WV | MEDICAID |