MEDICARE: DOMINION HEALTH MEDICAL ASSOC

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	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1457756322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMINION HEALTH MEDICAL ASSOC

Provider Business Mailing Address
First Line	:	PO BOX 860
Second Line	:
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-0860
Country	:	US
Telephone Number	:	434-517-3513
Fax Number	:	434-572-4549

Provider Business Practice Location Address
First Line	:	101 AUBREYS LOOP
Second Line	:
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-5054
Country	:	US
Telephone Number	:	434-517-3879
Fax Number	:	434-517-3989

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. CECIL HAZELWOOD
Credential	:
Telephone Number	:	434-517-3515

Provider Enumeration Date	:	11/04/2014
Last Update Date	:	11/04/2014

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Directions to “DOMINION HEALTH MEDICAL ASSOC ” Practice Location

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