Healthcare Provider Details

I. General information

NPI: 1801175567
Provider Name (Legal Business Name): DOMINION HEALTH MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 WILBORN AVE
SOUTH BOSTON VA
24592-1662
US

IV. Provider business mailing address

PO BOX 777
SOUTH BOSTON VA
24592-0777
US

V. Phone/Fax

Practice location:
  • Phone: 434-517-3100
  • Fax:
Mailing address:
  • Phone: 434-517-3513
  • Fax: 434-572-4549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0101037012
License Number StateVA

VIII. Authorized Official

Name: STEWART NELSON
Title or Position: CEO
Credential:
Phone: 434-517-3183