Provider Demographics
NPI:1952330193
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:PRINCE GEORGE COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DISTRICT HEALTH DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RANKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-863-1652
Mailing Address - Street 1:6459 ADMINISTRATION DR.
Mailing Address - Street 2:
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875
Mailing Address - Country:US
Mailing Address - Phone:804-733-2630
Mailing Address - Fax:804-862-6127
Practice Address - Street 1:6459 ADMINISTRATION DR.
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875
Practice Address - Country:US
Practice Address - Phone:804-733-2630
Practice Address - Fax:804-862-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA41196OtherOPTIMA/SENTARA
VA42517OtherSOUTHERN HEALTH
VA266463OtherANTHEM
VA004975863Medicaid
VA45763OtherCARENET
VA85733OtherVIRGINIA PREMIER
VA85733OtherVIRGINIA PREMIER