Provider Demographics
NPI:1942306659
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:CHARLOTTE 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 695
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE COURT HOUSE
Mailing Address - State:VA
Mailing Address - Zip Code:23923-0695
Mailing Address - Country:US
Mailing Address - Phone:434-542-5251
Mailing Address - Fax:434-542-4354
Practice Address - Street 1:270 DAVID BRUCE AVENUE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE COURT HOUSE
Practice Address - State:VA
Practice Address - Zip Code:23923-0695
Practice Address - Country:US
Practice Address - Phone:434-542-5251
Practice Address - Fax:434-542-4354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0004975391Medicaid
VA0004975391Medicaid