Provider Demographics
NPI:1710938576
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:MECKLENBURG COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOUTHSIDE HEALTH DISTRICT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPILLMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:434-738-6545
Mailing Address - Street 1:969 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BOYDTON
Mailing Address - State:VA
Mailing Address - Zip Code:23917-3418
Mailing Address - Country:US
Mailing Address - Phone:434-738-6545
Mailing Address - Fax:434-738-6295
Practice Address - Street 1:969 MADISON ST
Practice Address - Street 2:
Practice Address - City:BOYDTON
Practice Address - State:VA
Practice Address - Zip Code:23917
Practice Address - Country:US
Practice Address - Phone:434-738-6545
Practice Address - Fax:434-738-6295
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-15
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1010243863251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005840686Medicaid
VA29006OtherOPTIMA
VA266538OtherANTHEM BCBS
VA004975723Medicaid
VA4975723Medicaid
VA29006OtherOPTIMA
G24972Medicare UPIN
VAC10827Medicare PIN
VA266538OtherANTHEM BCBS
VAC10827Medicare PIN