Provider Demographics
NPI:1639284979
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:PULASKI COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NOELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BISSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-381-7100
Mailing Address - Street 1:170 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:VA
Mailing Address - Zip Code:24301-4524
Mailing Address - Country:US
Mailing Address - Phone:540-994-5030
Mailing Address - Fax:540-994-5036
Practice Address - Street 1:170 4TH ST NW
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301-4524
Practice Address - Country:US
Practice Address - Phone:540-994-5030
Practice Address - Fax:540-994-5036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004975880Medicaid
VA435418OtherANTHEM/BC/HEALTHKEEPERS
VA412938OtherSOUTHERNHEALTH
VA004975880Medicaid
VA435418OtherANTHEM/BC/HEALTHKEEPERS
VA600000020Medicare PIN