Basic Information
| Provider Information | |||||||||
| NPI: | 1013977933 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HALIFAX REGIONAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SENTARA HALIFAX HOSPICE AND PALLIATIVE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921645 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2204 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173100 | ||||||||
| FaxNumber: | 4345756752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 02/05/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLUGE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4345173100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | HSP-0621 | VA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 442470 | 01 | VA | HOSPICE BCBS PROVIDER NUM | OTHER | 4910231 | 05 | VA | MEDICAID |