Basic Information
| Provider Information | |||||||||
| NPI: | 1801175567 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOMINION HEALTH MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HALIFAX UROLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 777 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245920777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173513 | ||||||||
| FaxNumber: | 4345724549 | ||||||||
| Practice Location | |||||||||
| Address1: | 2232 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2011 | ||||||||
| LastUpdateDate: | 08/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | STEWART | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4345173183 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 0101037012 | VA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.