NPIMap

Organization Active NPI

Southern Dominion Health System, Inc.

Doing business as Dinwiddie Medical Center

  • Federally Qualified Health Center (FQHC)
  • Dinwiddie, VA
National Provider Identifier
1487867206
Registry record updated Feb 7, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SOUTHERN DOMINION HEALTH SYSTEM, INC.
Doing business as
Dinwiddie Medical Center
Practice address
13855 Courthouse Rd
Dinwiddie, VA 23841-2254
Phone
(804) 469-3731
Fax
(804) 469-5307
NPI assigned
May 8, 2007
Last updated
Feb 7, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SOUTHERN DOMINION HEALTH SYSTEM, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 7, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
April King
Title
Ceo
Phone
(434) 696-2165

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU
Federally Qualified Health Center (FQHC) 261QF0400X VA Primary

Addresses

Primary practice location

13855 Courthouse Rd
Dinwiddie, VA 23841-2254

Mailing address

PO Box 70
Victoria, VA 23974-0070
Phone (434) 696-2165

Other identifiers 1

IdentifierTypeStateIssuer
007604025MedicaidVA

Other names 1

  • Dinwiddie Medical Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040611000631 VA Part B Supplier - Clinic/Group Practice 0648188755 Receives reassigned benefits from 25 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Amelia, VA; Dinwiddle, VA; Emporia, VA; Victoria, VA
O20080110000518 VA Part A Provider - Federally Qualified Health Center (FQHC) 0648188755 Practice locations: Dinwiddie, VA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1487867206. Details of each certification follow.

Federally qualified health center certification: CCN 491845

Legal name
SOUTHERN DOMINION HEALTH SYSTEM INC
Doing business as
DINWIDDIE MEDICAL CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 3, 2000
Last certification
Apr 3, 2000
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1985 in VA
Enrollment address
13855 Courthouse Rd
Dinwiddie, VA 23841-2254

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Amelia Health Care Cent

Locations

8920 Otterburn Rd
Amelia Ct Hse, VA 23002
Phone (804) 288-8838

Ownership & related parties

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Edward H Jeter Individual Corporate DirectorChairman Apr 18, 1994 8%
Beatrice O Head Individual Corporate DirectorBoard Member Nov 15, 2010 8%
Anne G Gaulding Individual Corporate DirectorBoard Member Sep 21, 2009 8%
Mary H Stewart Individual Corporate DirectorBoard Member Apr 15, 2019
Harold M Walker Individual Corporate DirectorBoard Member Jul 16, 2001 8%
Robert E Clement Individual Corporate DirectorBoard Member Jan 17, 2000 8%
April L King Individual Corporate DirectorCeo Apr 19, 2022
Angela B Wilson Individual Corporate DirectorBoard Member Sep 16, 2002 8%
Wanda S Hill Individual Corporate DirectorBoard Member Nov 15, 2010 8%
Jill W Seamans Individual Corporate OfficerCeo Aug 13, 2015
W-2 Managing EmployeeCeo Aug 13, 2015
Luther M Drummard Individual Corporate DirectorBoard Member Sep 13, 2006 8%
Eileen E Duffy Individual Corporate DirectorBoard Member Jun 19, 1995 8%
Rebecca P Reitz Individual Corporate DirectorBoard Member Aug 20, 2018
April S Long Individual Corporate DirectorBoard Member Aug 20, 2018

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178582400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707264000000",
    "number": "1487867206",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 70",
            "city": "VICTORIA",
            "state": "VA",
            "postal_code": "239740070",
            "telephone_number": "434-696-2165",
            "fax_number": "434-696-1378"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13855 COURTHOUSE RD",
            "city": "DINWIDDIE",
            "state": "VA",
            "postal_code": "238412254",
            "telephone_number": "804-469-3731",
            "fax_number": "804-469-5307"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN DOMINION HEALTH SYSTEM, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHERN DOMINION HEALTH SYSTEM, INC.",
        "enumeration_date": "2007-05-08",
        "last_updated": "2024-02-07",
        "certification_date": "2024-02-07",
        "status": "A",
        "authorized_official_last_name": "KING",
        "authorized_official_first_name": "APRIL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "434-696-2165"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "VA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "007604025",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dinwiddie Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dinwiddie, VA

Sources for this page

Verify at the official NPI Registry.