MEDICARE: COMMONWEALTH OF VIRGINIA SOUTHSIDE VA TRAINING CENTER

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	208M00000X	Hospitalist Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CO2260	OTHER	VA	PHYSICIAN GROUP NUMBER

General Provider Information

NPI Number	:	1639232408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF VIRGINIA SOUTHSIDE VA TRAINING CENTER

Provider Business Mailing Address
First Line	:	PO BOX 4030
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-0030
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	26317 W. WASHINGTON STREET
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-0000
Country	:	US
Telephone Number	:	804-524-7537
Fax Number	:

Authorized Official
Title or Position	:	FACILITY DIRECTOR
Name	:	JOHN HOLLAND JR.
Credential	:	M.D.
Telephone Number	:	804-524-7537

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	08/22/2020

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