Basic Information
| Provider Information | |||||||||
| NPI: | 1134407570 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOMINION HEALTH MEDICAL ASSOC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SENTARA HALIFAX EMERGENCY PHYSICIAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 860 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173513 | ||||||||
| FaxNumber: | 4345173887 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173529 | ||||||||
| FaxNumber: | 4345173887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2011 | ||||||||
| LastUpdateDate: | 02/10/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | HAZELWOOD | ||||||||
| AuthorizedOfficialFirstName: | CECIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER DHMA | ||||||||
| AuthorizedOfficialTelephone: | 4345173515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
No ID Information.