Provider Demographics
NPI:1104067701
Name:SOUTHERN DOMINION HEALTH SYSTEM
Entity type:Organization
Organization Name:SOUTHERN DOMINION HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:434-696-2165
Mailing Address - Street 1:8631 NAMOZINE RD
Mailing Address - Street 2:
Mailing Address - City:AMELIA COURT HOUSE
Mailing Address - State:VA
Mailing Address - Zip Code:23002-3410
Mailing Address - Country:US
Mailing Address - Phone:804-561-6263
Mailing Address - Fax:
Practice Address - Street 1:8631 NAMOZINE RD
Practice Address - Street 2:
Practice Address - City:AMELIA COURT HOUSE
Practice Address - State:VA
Practice Address - Zip Code:23002-3410
Practice Address - Country:US
Practice Address - Phone:804-561-6263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center