Basic Information
| Provider Information | |||||||||
| NPI: | 1801030119 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HALIFAX INTERNAL MEDICINE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2232 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173879 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2232 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173879 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2009 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | KETCHERSID | ||||||||
| AuthorizedOfficialFirstName: | MARIE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4345173879 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 0101054916 | VA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
No ID Information.