Basic Information
| Provider Information | |||||||||
| NPI: | 1891786570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HALIFAX REGIONAL HOSPITAL, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173100 | ||||||||
| FaxNumber: | 4345173819 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173100 | ||||||||
| FaxNumber: | 4345173819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | ELLIOTT | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | WOMACK | ||||||||
| AuthorizedOfficialTitleorPosition: | COORDINATOR THIRD PARTY PAYERS | ||||||||
| AuthorizedOfficialTelephone: | 4345173156 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | H1853 | VA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004952294 | 05 | VA | MEDICAID | 8536228 | 05 | VA | MEDICAID | 000054 | 01 | VA | ANTHEM PROVIDER # | OTHER | 004900138 | 05 | VA | MEDICAID |