MEDICARE: HALIFAX REGIONAL HOSPITAL, INC

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	H1853	VA

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000054	OTHER	VA	ANTHEM PROVIDER #
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1891786570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HALIFAX REGIONAL HOSPITAL, INC

Provider Business Mailing Address
First Line	:	2204 WILBORN AVE
Second Line	:
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-1645
Country	:	US
Telephone Number	:	434-517-3100
Fax Number	:	434-517-3819

Provider Business Practice Location Address
First Line	:	2204 WILBORN AVE
Second Line	:
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-1645
Country	:	US
Telephone Number	:	434-517-3100
Fax Number	:	434-517-3819

Authorized Official
Title or Position	:	COORDINATOR THIRD PARTY PAYERS
Name	:	MRS. STEPHANIE WOMACK ELLIOTT
Credential	:
Telephone Number	:	434-517-3156

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	07/08/2010

75 FRANCIS STREET , BRIGHAM INTERNAL MEDICARE ASSOCIATES
BOSTON, MA
02115

Practice Phone: 617-732-6049
Practice Fax: 617-264-5202