Provider Demographics
NPI:1750447009
Name:COMMUNITY MEMORIAL HEALTHCENTER
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HEALTHCENTER
Other - Org Name:CMH SPECIALTY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:VP OF FINANCE & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:434-774-2400
Mailing Address - Street 1:142 E FERRELL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 E FERRELL ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-2102
Practice Address - Country:US
Practice Address - Phone:434-774-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008834393Medicaid
NC89016G6Medicaid