Provider Demographics
NPI:1760740625
Name:DOMINION HEALTH MEDICAL ASSOC
Entity Type:Organization
Organization Name:DOMINION HEALTH MEDICAL ASSOC
Other - Org Name:SENTARA HALIFAX NEUROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER (SDHG)
Authorized Official - Prefix:
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZELWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-517-3515
Mailing Address - Street 1:P.O. BOX 860
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592
Mailing Address - Country:US
Mailing Address - Phone:434-517-3513
Mailing Address - Fax:434-517-3887
Practice Address - Street 1:2206 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592
Practice Address - Country:US
Practice Address - Phone:434-517-8075
Practice Address - Fax:434-517-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101251410261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101251410OtherLICENSE