Provider Demographics
NPI:1831292325
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DISTRICT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:TWEEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:804-556-5843
Mailing Address - Street 1:PO BOX 178
Mailing Address - Street 2:1800 SANDYHOOK RD
Mailing Address - City:GOOCHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23063-0178
Mailing Address - Country:US
Mailing Address - Phone:804-556-5843
Mailing Address - Fax:804-556-3707
Practice Address - Street 1:1800 SANDYHOOK RD
Practice Address - Street 2:
Practice Address - City:GOOCHLAND
Practice Address - State:VA
Practice Address - Zip Code:23063-0178
Practice Address - Country:US
Practice Address - Phone:804-556-5843
Practice Address - Fax:804-556-3707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004975537Medicaid
PH5001Medicare UPIN
VA004975537Medicaid