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	251K00000X	Public Health or Welfare Agency

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

General Provider Information

NPI Number	:	1740386457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Provider Business Mailing Address
First Line	:	PO BOX 198
Second Line	:
City	:	BUCKINGHAM
State	:	VA
Zip	:	23921-0198
Country	:	US
Telephone Number	:	434-969-4244
Fax Number	:	434-969-1292

Provider Business Practice Location Address
First Line	:	13360 WEST JAMES ANDERSON HWY
Second Line	:
City	:	BUCKINGHAM
State	:	VA
Zip	:	23921-0198
Country	:	US
Telephone Number	:	434-969-4244
Fax Number	:	434-696-1292

Authorized Official
Title or Position	:	DISTRICT HEALTH DIRECTOR
Name	:	DR. ALEXANDER P SAMUEL
Credential	:	M.D.
Telephone Number	:	434-392-3984

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	09/21/2010

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