Basic Information
| Provider Information | |||||||||
| NPI: | 1689772238 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOMINION HEALTH MEDICAL ASSOC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SENTARA CHASE CITY FAMILY MEDICINE | ||||||||
| 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: | 946 N. MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHASE CITY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343725141 | ||||||||
| FaxNumber: | 4345173887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 02/11/2015 | ||||||||
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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 | 173000000X | 0101032102 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 007610114 | 05 | VA | MEDICAID |