Provider Demographics
NPI:1487629374
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:SUFFOLK HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:TILLERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-514-4765
Mailing Address - Street 1:P.O. BOX 1587
Mailing Address - Street 2:135 HALL AVENUE, SUITE A
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4657
Mailing Address - Country:US
Mailing Address - Phone:757-514-4700
Mailing Address - Fax:757-514-4873
Practice Address - Street 1:135 HALL AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4657
Practice Address - Country:US
Practice Address - Phone:757-514-4700
Practice Address - Fax:757-514-4873
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-22
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008700664Medicaid
VA4972279Medicaid
VA4976240Medicaid
VA008770271Medicaid
VA4972279Medicaid
497065Medicare ID - Type UnspecifiedHOME HEALTH