Provider Demographics
NPI:1427306315
Name:DOMINION HEALTH MEDICAL ASSOC
Entity type:Organization
Organization Name:DOMINION HEALTH MEDICAL ASSOC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/SDHG
Authorized Official - Prefix:
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:F
Authorized Official - Last Name:HAZELWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-517-3515
Mailing Address - Street 1:P.O.BOX 860
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592
Mailing Address - Country:US
Mailing Address - Phone:434-517-3513
Mailing Address - Fax:434-517-3887
Practice Address - Street 1:2232 WILBORN AVE
Practice Address - Street 2:SUITE F
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592
Practice Address - Country:US
Practice Address - Phone:434-517-8095
Practice Address - Fax:434-517-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101251391OtherVIRGINIA LICENSE