Provider Demographics
NPI:1912003617
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:PRINCE EDWARD 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 1:111 SOUTH ST
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-1328
Mailing Address - Country:US
Mailing Address - Phone:434-392-8187
Mailing Address - Fax:434-392-1088
Practice Address - Street 1:111 SOUTH ST
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1328
Practice Address - Country:US
Practice Address - Phone:434-392-8187
Practice Address - Fax:434-392-1088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004975855Medicaid
VA004975855Medicaid