Provider Demographics
NPI:1801175567
Name:DOMINION HEALTH MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:DOMINION HEALTH MEDICAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-517-3183
Mailing Address - Street 1:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-0777
Mailing Address - Country:US
Mailing Address - Phone:434-517-3513
Mailing Address - Fax:434-572-4549
Practice Address - Street 1:2232 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1662
Practice Address - Country:US
Practice Address - Phone:434-517-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037012261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center