Healthcare Provider Details

I. General information

NPI: 1386737682
Provider Name (Legal Business Name): DOMINION HEALTH MEDICAL ASSOC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15210 L. P. BAILEY MEMORIAL HWY
SOUTH BOSTON VA
24592
US

IV. Provider business mailing address

P.O. BOX 860
SOUTH BOSTON VA
24592
US

V. Phone/Fax

Practice location:
  • Phone: 434-349-3113
  • Fax: 434-517-3887
Mailing address:
  • Phone: 434-517-3513
  • Fax: 434-517-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number0101032102
License Number StateVA

VIII. Authorized Official

Name: CECIL HAZELWOOD
Title or Position: MANAGER SDHG
Credential:
Phone: 434-517-3590