Healthcare Provider Details

I. General information

NPI: 1457756322
Provider Name (Legal Business Name): DOMINION HEALTH MEDICAL ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 AUBREYS LOOP
SOUTH BOSTON VA
24592-5054
US

IV. Provider business mailing address

PO BOX 860
SOUTH BOSTON VA
24592-0860
US

V. Phone/Fax

Practice location:
  • Phone: 434-517-3879
  • Fax: 434-517-3989
Mailing address:
  • Phone: 434-517-3513
  • Fax: 434-572-4549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CECIL HAZELWOOD
Title or Position: MANAGER
Credential:
Phone: 434-517-3515