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

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	072212	OTHER	VA	ANTHEM
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508951567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Provider Business Mailing Address
First Line	:	3810 NINE MILE RD
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23223-4848
Country	:	US
Telephone Number	:	804-652-3186
Fax Number	:	804-501-4588

Provider Business Practice Location Address
First Line	:	3810 NINE MILE RD
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23223-4848
Country	:	US
Telephone Number	:	804-652-3186
Fax Number	:	804-501-4588

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MRS. CARLA P. BENNETT
Credential	:
Telephone Number	:	804-501-4953

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	02/18/2011

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

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