=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942009196
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL QUENTIN HAZELWOOD MSA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2025
-----------------------------------------------------
Last Update Date | 03/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2204 WILBORN AVE
-----------------------------------------------------
City | SOUTH BOSTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24592-1645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-517-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1113 SLAYTON RD
-----------------------------------------------------
City | SUTHERLIN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24594-3121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-334-4211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | 0136000590
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------