1689772238 NPI number — DOMINION HEALTH MEDICAL ASSOC

Table of content: (NPI 1689772238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689772238 NPI number — DOMINION HEALTH MEDICAL ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOMINION HEALTH MEDICAL ASSOC
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:
1689772238
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 860
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BOSTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-517-3513
Provider Business Mailing Address Fax Number:
434-517-3887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
946 N. MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHASE CITY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-372-5141
Provider Business Practice Location Address Fax Number:
434-517-3887
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAZELWOOD
Authorized Official First Name:
CECIL
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MANAGER (SDHG)
Authorized Official Telephone Number:
434-517-3515

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  0101032102 , 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: 007610114 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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