MEDICARE: COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251K00000X	Public Health or Welfare Agency
2	251K00000X	Public Health or Welfare Agency		VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	27523	OTHER	VA	OPTIMA/SENTARA
3	007600399	OTHER	VA	VIRGINIA PREMIER

General Provider Information

NPI Number	:	1023049517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Provider Business Mailing Address
First Line	:	608 JACKSON STREET
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-5719
Country	:	US
Telephone Number	:	540-899-4797
Fax Number	:	540-899-4599

Provider Business Practice Location Address
First Line	:	10708 BALLANTRAYE DRIVE
Second Line	:	SUITE 204
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22407-4701
Country	:	US
Telephone Number	:	540-891-3151
Fax Number	:	540-891-3152

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. BROOKE W ROSSHEIM
Credential	:	M.D., M.P.H.
Telephone Number	:	540-899-4797

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	06/13/2011

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Directions to “COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH ” Practice Location

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