MEDICARE: PETERSBURG CASE MANAGEMENT & SERVICES

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1942360201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSBURG CASE MANAGEMENT & SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 725
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23804-0725
Country	:	US
Telephone Number	:	804-721-3856
Fax Number	:	804-861-0426

Provider Business Practice Location Address
First Line	:	114 S ADAMS ST
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-4511
Country	:	US
Telephone Number	:	804-721-3856
Fax Number	:	804-861-0426

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JAMES QUINCY DAVIS SR.
Credential	:
Telephone Number	:	804-721-3856

Provider Enumeration Date	:	12/09/2006
Last Update Date	:	04/11/2008

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