Basic Information
| Provider Information | |||||||||
| NPI: | 1104899319 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PETERSBURG HOSPITAL COMPANY LLC | ||||||||
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| OtherOrganizationName: | SOUTHSIDE REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 501128 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631501128 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 MEDICAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047655000 | ||||||||
| FaxNumber: | 8047655962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | LALOR | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6159254565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H1905 | VA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 311407 | 01 | ALLIANCE | OTHER | 214643 | 01 | SOUTHERN HLTH SVC | OTHER | 442490 | 01 | BCBS | OTHER | 442490 | 01 | BC AL | OTHER | 138348 | 01 | BCBS | OTHER | 4900677 | 05 | VA | MEDICAID | 138348 | 01 | MO2 BC AL | OTHER | 4900067 | 05 | NC | MEDICAID |