Provider Demographics
NPI:1184680126
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:BRUNSWICK COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOUTHSIDE HEALTH DISTRICT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPILLMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:434-738-6545
Mailing Address - Street 1:1632 LAWRENCEVILLE PLANK RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23868-3304
Mailing Address - Country:US
Mailing Address - Phone:434-848-2525
Mailing Address - Fax:434-848-2235
Practice Address - Street 1:1632 LAWRENCEVILLE PLANK RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23868
Practice Address - Country:US
Practice Address - Phone:434-848-2525
Practice Address - Fax:434-848-2235
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-26
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1010243863251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005840686Medicaid
VA266536OtherANTHEM BCBS
VA004975332Medicaid
VA41172OtherOPTIMA
VA4975332Medicaid
2072034AMedicare PIN
VA004975332Medicaid
VA266536OtherANTHEM BCBS
118586Medicare UPIN
VA4975332Medicaid
VAC10827Medicare PIN
VAC10827Medicare PIN