Provider Demographics
NPI:1871513630
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-748-1630
Mailing Address - Street 1:PO BOX 3401
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-9001
Mailing Address - Country:US
Mailing Address - Phone:804-520-9380
Mailing Address - Fax:804-520-9222
Practice Address - Street 1:200 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3142
Practice Address - Country:US
Practice Address - Phone:804-520-9380
Practice Address - Fax:804-520-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
41175OtherOPTIMA FAMILY CARE
VA004976479Medicaid
12502OtherCARENET/SOUTHERN HEALTH
4976479OtherVIRGINIA PREMIER HEALTH
VA266458OtherANTHEM BLUE CROSS BSHIELD
VA004976479Medicaid
4976479OtherVIRGINIA PREMIER HEALTH
990000666Medicare ID - Type UnspecifiedMEDICARE PART B RAILROAD