1184668477 NPI number — COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Table of content: (NPI 1184668477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184668477 NPI number — COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
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:
6
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:
1184668477
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
608 JACKSON STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22401-5719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-899-4797
Provider Business Mailing Address Fax Number:
540-899-4599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10079 KINGS HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KING GEORGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22485-3445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-775-3111
Provider Business Practice Location Address Fax Number:
540-775-3109
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROSSHEIM
Authorized Official First Name:
BROOKE
Authorized Official Middle Name:
W
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
540-899-4797

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251K00000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000030996 . This is a "MEDICAID-SLH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 004975634 . This is a "VIRGINIA PREMIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 266520 . This is a "ANTHEM HK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00193783 . This is a "MEDICARE-R/R" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 418740 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 004975634 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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