Provider Demographics
NPI:1447362660
Name:COMMONWEALTH OF VIRGINIA HIRAM W DAVIS MEDICAL CENTER
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA HIRAM W DAVIS MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JARVIS
Authorized Official - Middle Name:T
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:DHA, LNHA, CPHQ
Authorized Official - Phone:804-524-7112
Mailing Address - Street 1:PO BOX 4030
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-0030
Mailing Address - Country:US
Mailing Address - Phone:804-524-7344
Mailing Address - Fax:804-524-7148
Practice Address - Street 1:ALBEMARLE AND 7TH STREETS
Practice Address - Street 2:BUILDING 110
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-0030
Practice Address - Country:US
Practice Address - Phone:804-524-7344
Practice Address - Fax:804-524-7148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4967615Medicaid