Provider Demographics
NPI:1184668477
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:KING GEORGE HEALTH DEPARTMENT
Other - Org Type:Doing Business As
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, MPH
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 1:10079 KINGS HIGHWAY
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-3445
Practice Address - Country:US
Practice Address - Phone:540-775-3111
Practice Address - Fax:540-775-3109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X
VA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000030996OtherMEDICAID-SLH
VA004975634OtherVIRGINIA PREMIER
VA266520OtherANTHEM HK
VAP00193783OtherMEDICARE-R/R
VA418740OtherSOUTHERN HEALTH
VA004975634Medicaid
VA418740OtherSOUTHERN HEALTH