Basic Information
| Provider Information | |||||||||
| NPI: | 1427306315 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOMINION HEALTH MEDICAL ASSOC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SENTORA SOUTHERN VIRGINIA EAR ,NOSE,THROAT | ||||||||
| 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: | 2232 WILBORN AVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345178095 | ||||||||
| FaxNumber: | 4345173887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2012 | ||||||||
| LastUpdateDate: | 02/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | HAZELWOOD | ||||||||
| AuthorizedOfficialFirstName: | CECIL | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER/SDHG | ||||||||
| AuthorizedOfficialTelephone: | 4345173515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0101251391 | 01 | VA | VIRGINIA LICENSE | OTHER |