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General NPI Number Information
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NPI Number | 1952465064
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Entity Type | Organization
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Legal Business Name | HALIFAX RADIOLOGICAL ASSOCIATES, INC.
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Dates
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Enumeration Date | 12/21/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2204 WILBORN AVE RADIOLOGY DEPARTMENT
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City | SOUTH BOSTON
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State | VA
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Zip | 24592-1645
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Country | US
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Telephone | 434-517-3187
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Fax | 434-517-3686
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Provider Business Mailing Address
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Address Line | 2204 WILBORN AVE RADIOLOGY DEPARTMENT
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City | SOUTH BOSTON
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State | VA
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Zip | 24592-1645
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Country | US
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Telephone | 434-517-3187
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Fax | 434-517-3686
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Authorized Official
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Title or Position | PRESIDENT
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Name | ELMER SAN PEDRO
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Credential | M.D.
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Telephone | 434-517-3686
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0101027902
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License Number State | VA
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