Provider Demographics
NPI:1669574042
Name:COMMONWEALTH OF VIRGINIA CENTRAL STATE HOSPITAL
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA CENTRAL STATE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-524-7000
Mailing Address - Street 1:PO BOX 4030
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-0030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26317 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803
Practice Address - Country:US
Practice Address - Phone:804-524-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL STATE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-05
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49410701Medicaid
VAC02266Medicare PIN