Provider Demographics
NPI:1376595785
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:ROANOKE CITY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENN-TIMITY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-204-9718
Mailing Address - Street 1:1502 WILLIAMSON RD NE
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-5130
Mailing Address - Country:US
Mailing Address - Phone:540-283-5050
Mailing Address - Fax:540-857-7316
Practice Address - Street 1:1502 WILLIAMSON RD NE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-5130
Practice Address - Country:US
Practice Address - Phone:540-283-5050
Practice Address - Fax:540-857-7316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4975022Medicaid
VA600699121Medicare PIN