Provider Demographics
NPI:1467630731
Name:SOUTHERN DOMINION HEALTH SYSTEM INC
Entity type:Organization
Organization Name:SOUTHERN DOMINION HEALTH SYSTEM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:O
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:434-696-2165
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23974-0070
Mailing Address - Country:US
Mailing Address - Phone:434-696-2165
Mailing Address - Fax:434-696-1557
Practice Address - Street 1:1508 K V ROAD
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:VA
Practice Address - Zip Code:23974-0070
Practice Address - Country:US
Practice Address - Phone:434-696-2165
Practice Address - Fax:434-696-1557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007691084Medicaid
VA491857Medicare Oscar/Certification
VAC01677Medicare PIN