Provider Demographics
NPI:1487867206
Name:SOUTHERN DOMINION HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:SOUTHERN DOMINION HEALTH SYSTEM, INC.
Other - Org Name:DINWIDDIE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-696-2165
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23974-0070
Mailing Address - Country:US
Mailing Address - Phone:434-696-2165
Mailing Address - Fax:434-696-1378
Practice Address - Street 1:13855 COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23841-2254
Practice Address - Country:US
Practice Address - Phone:804-469-3731
Practice Address - Fax:804-469-5307
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN DOMINION HEALTH SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-08
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
VA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007604025Medicaid
VA007604025Medicaid
VAC08100Medicare PIN