Basic Information
Provider Information
NPI: 1760740625
EntityType: 2
ReplacementNPI:  
OrganizationName: DOMINION HEALTH MEDICAL ASSOC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SENTARA HALIFAX NEUROLOGY
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: P.O. BOX 860
Address2:  
City: SOUTH BOSTON
State: VA
PostalCode: 24592
CountryCode: US
TelephoneNumber: 4345173513
FaxNumber: 4345173887
Practice Location
Address1: 2206 WILBORN AVE
Address2:  
City: SOUTH BOSTON
State: VA
PostalCode: 24592
CountryCode: US
TelephoneNumber: 4345178075
FaxNumber: 4345173887
Other Information
ProviderEnumerationDate: 04/30/2012
LastUpdateDate: 02/10/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: HAZELWOOD
AuthorizedOfficialFirstName: CECIL
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: MANAGER (SDHG)
AuthorizedOfficialTelephone: 4345173515
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261Q00000X0101251410VAY Ambulatory Health Care FacilitiesClinic/Center 

ID Information
IDTypeStateIssuerDescription
010125141001VALICENSEOTHER


Home