Provider Demographics
NPI:1245393685
Name:PETERSBURG HOSPITAL COMPANY LLC
Entity Type:Organization
Organization Name:PETERSBURG HOSPITAL COMPANY LLC
Other - Org Name:SOUTHSIDE REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-925-4565
Mailing Address - Street 1:P O BOX 501128
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150
Mailing Address - Country:US
Mailing Address - Phone:804-765-5000
Mailing Address - Fax:804-765-5962
Practice Address - Street 1:3335 S CRATER RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9214
Practice Address - Country:US
Practice Address - Phone:804-862-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA138346OtherANTHEM BL CR BL SH