Provider Demographics
NPI:1639232408
Name:COMMONWEALTH OF VIRGINIA SOUTHSIDE VA TRAINING CENTER
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA SOUTHSIDE VA TRAINING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:804-524-7537
Mailing Address - Street 1:PO BOX 4030
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-0030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26317 W. WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-0000
Practice Address - Country:US
Practice Address - Phone:804-524-7537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACO2260OtherPHYSICIAN GROUP NUMBER