Provider Demographics
NPI:1336170745
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROSSHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MHP
Authorized Official - Phone:540-899-4797
Mailing Address - Street 1:608 JACKSON STREET
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-5719
Mailing Address - Country:US
Mailing Address - Phone:540-899-4797
Mailing Address - Fax:540-899-4599
Practice Address - Street 1:608 JACKSON STREET
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5719
Practice Address - Country:US
Practice Address - Phone:540-899-4142
Practice Address - Fax:540-899-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA266518OtherANTHEM-HK
VA000036307OtherMEDICAID-SLH
VA418625OtherSOUTHERN HEALTH
VA6000000943OtherMEDICARE R/R
VA004976142OtherVA PREMIER
VA004976142Medicaid
VA000036307Medicaid
VA000036307OtherMEDICAID-SLH