Provider Demographics
NPI:1821194549
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:AMELIA COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DISTRICT HEALTH DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:P
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-392-3984
Mailing Address - Street 1:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:AMELIA COURT HOUSE
Mailing Address - State:VA
Mailing Address - Zip Code:23002-0392
Mailing Address - Country:US
Mailing Address - Phone:804-561-2711
Mailing Address - Fax:804-561-2712
Practice Address - Street 1:16320 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:VA
Practice Address - Zip Code:23002-4817
Practice Address - Country:US
Practice Address - Phone:804-561-2711
Practice Address - Fax:804-561-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004975243Medicaid
VA004975243Medicaid