Provider Demographics
NPI:1457756322
Name:DOMINION HEALTH MEDICAL ASSOC
Entity Type:Organization
Organization Name:DOMINION HEALTH MEDICAL ASSOC
Other - Org Name:SENTARA HALIFAX PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
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:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-0860
Mailing Address - Country:US
Mailing Address - Phone:434-517-3513
Mailing Address - Fax:434-572-4549
Practice Address - Street 1:101 AUBREYS LOOP
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-5054
Practice Address - Country:US
Practice Address - Phone:434-517-3879
Practice Address - Fax:434-517-3989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty