Basic Information
| Provider Information | |||||||||
| NPI: | 1992724033 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HALIFAX REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SENTARA HALIFAX REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173100 | ||||||||
| FaxNumber: | 4345750377 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 WILBORN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245921645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173100 | ||||||||
| FaxNumber: | 4345750377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 04/09/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELLIOTT | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | COORDINATOR THIRD PARTY PAYERS | ||||||||
| AuthorizedOfficialTelephone: | 4345173156 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246Q00000X | H1853 | VA | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Pathology | 246W00000X | H1853 | VA | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Technician, Cardiology | 282N00000X | H1853 | VA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 005831300 | 05 | VA | MEDICAID | 006041736 | 05 | VA | MEDICAID | 006072097 | 05 | VA | MEDICAID | 006604510 | 05 | VA | MEDICAID | 010053871 | 05 | VA | MEDICAID | 010110041 | 05 | VA | MEDICAID | 005802334 | 05 | VA | MEDICAID | 005810922 | 05 | VA | MEDICAID | 010263867 | 05 | VA | MEDICAID | 006017738 | 05 | VA | MEDICAID | 006081011 | 05 | VA | MEDICAID | 005875251 | 05 | VA | MEDICAID | 006089526 | 05 | VA | MEDICAID | 005828902 | 05 | VA | MEDICAID | 006086675 | 05 | VA | MEDICAID | 006087701 | 05 | VA | MEDICAID | 007306628 | 05 | VA | MEDICAID |