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	96857	OTHER	VA	OPTIMA
2	61557	OTHER	VA	CARENET
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	087342	OTHER	VA	ANTHEM
5	004975359	OTHER	VA	VIRGINIA PREMIER

General Provider Information

NPI Number	:	1710949771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Provider Business Mailing Address
First Line	:	PO BOX 160
Second Line	:
City	:	RUSTBURG
State	:	VA
Zip	:	24588-0160
Country	:	US
Telephone Number	:	434-332-9550
Fax Number	:	434-332-5512

Provider Business Practice Location Address
First Line	:	116 KABLER LANE
Second Line	:
City	:	RUSTBURG
State	:	VA
Zip	:	24588
Country	:	US
Telephone Number	:	434-332-9550
Fax Number	:	434-332-5512

Authorized Official
Title or Position	:	DIRECTOR CENTRAL VA HEALTH DISTRIC
Name	:	DR. KERRY W GATELEY
Credential	:	MD, MPH, CPE
Telephone Number	:	434-947-6777

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	08/29/2008

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

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