Provider Demographics
NPI:1710949771
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:CAMPBELL COUNTYHEALTH DEPT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR CENTRAL VA HEALTH DISTRIC
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:GATELEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH, CPE
Authorized Official - Phone:434-947-6777
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:RUSTBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24588-0160
Mailing Address - Country:US
Mailing Address - Phone:434-332-9550
Mailing Address - Fax:434-332-5512
Practice Address - Street 1:116 KABLER LANE
Practice Address - Street 2:
Practice Address - City:RUSTBURG
Practice Address - State:VA
Practice Address - Zip Code:24588
Practice Address - Country:US
Practice Address - Phone:434-332-9550
Practice Address - Fax:434-332-5512
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-05
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA96857OtherOPTIMA
VA61557OtherCARENET
VA004975359Medicaid
VA087342OtherANTHEM
VA004975359OtherVIRGINIA PREMIER
VA004975359OtherVIRGINIA PREMIER
VA600001818Medicare PIN
VA087342OtherANTHEM