Healthcare Provider Details

I. General information

NPI: 1457415291
Provider Name (Legal Business Name): COMMONWEALTH OF VIRGINIA CENTRAL STATE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26317 W WASHINGTON STREET
PETERSBURG VA
23803
US

IV. Provider business mailing address

PO BOX 4030
PETERSBURG VA
23803-0030
US

V. Phone/Fax

Practice location:
  • Phone: 804-524-7000
  • Fax:
Mailing address:
  • Phone: 804-524-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES DAVIS
Title or Position: FACILITY DIRECTOR
Credential: M.D.
Phone: 804-524-7373