MEDICARE: COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	47211	OTHER	VA	SENTARA HEALTH PROVIDER #
4	089265	OTHER	VA	ANTHEM PROVIDER NUMBER
5	84962	OTHER	VA	VIRGINIA PREMIER PROVID #

General Provider Information

NPI Number	:	1144298142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Provider Business Mailing Address
First Line	:	3130 VICTORIA BLVD
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23661-1544
Country	:	US
Telephone Number	:	757-727-1172
Fax Number	:	757-727-1185

Provider Business Practice Location Address
First Line	:	3130 VICTORIA BLVD
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23661-1544
Country	:	US
Telephone Number	:	757-727-1172
Fax Number	:	757-727-1185

Authorized Official
Title or Position	:	DISTRICT DIRECTOR
Name	:	DR. SAMUEL W BERG
Credential	:	M.D., M.P.H.
Telephone Number	:	757-727-1172

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	09/19/2008

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Directions to “COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH ” Practice Location

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