NPIMap

Organization Active NPI

Southern Dominion Health System, Inc.

Doing business as Amelia Healthcare Center

  • Federally Qualified Health Center (FQHC)
  • Amelia Court House, VA
National Provider Identifier
1700099512
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
Amelia Healthcare Center
Practice address
8920 Otterburn Rd
Amelia Court House, VA 23002-4854
Phone
(804) 561-5150
Fax
(804) 561-6643
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
Federally Qualified Health Center (FQHC) 261QF0400X VA Primary

Addresses

Primary practice location

8920 Otterburn Rd
Amelia Court House, VA 23002-4854

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
010192862MedicaidVA

Other names 1

  • Amelia Healthcare 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
O20050516000658 VA Part A Provider - Federally Qualified Health Center (FQHC) 0648188755 Practice locations: Amelia Court House, VA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1700099512. Details of each certification follow.

Federally qualified health center certification: CCN 491864

Legal name
SOUTHERN DOMINION HEALTH SYSTEM INC
Doing business as
AMELIA HEALTHCARE CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 18, 2005
Last certification
May 18, 2005
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1985 in VA
Enrollment address
8920 Otterburn Rd
Amelia Court House, VA 23002-4854

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.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
49D1009858Amelia Healthcare Center-SDHS Inc8920 Otterburn Road, Amelia, VA 23002Provider-performed microscopyFeb 26, 2027

National Provider Directory

National Provider Directory
Part of
Linenburg Medical Cente

Locations

13855 Courthouse Rd
Dinwiddie, VA 23841
Phone (804) 469-3731

510 N Main St
Emporia, VA 23847
Phone (434) 634-7723

119 W 7th Ave
Kenbridge, VA 23944
Phone (434) 676-9355

Ownership & related parties

All disclosed owners & managing parties 16

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 9%
Beatrice O Head Individual Corporate DirectorBoard Member Nov 15, 2010 9%
Anne G Gaulding Individual Corporate DirectorBoard Member Sep 21, 2009 9%
Mary H Stewart Individual Corporate DirectorBoard Member Mar 18, 2019
Harold M Walker Individual Corporate DirectorBoard Member Jul 16, 2001 9%
Robert E Clement Individual Corporate DirectorBoard Member Jan 17, 2000 9%
April L King Individual Corporate OfficerCeo Apr 19, 2022
Angela B Wilson Individual Corporate DirectorBoard Member Sep 16, 2002 9%
Julie W Ashman Individual Corporate DirectorBoard Member Nov 21, 2022
Wanda S Hill Individual Corporate DirectorBoard Member Nov 15, 2010 9%
Jill W Seamans Individual Corporate DirectorBoard Member Apr 19, 2022
W-2 Managing EmployeeCfo Apr 19, 2022
Luther M Drummard Individual Corporate DirectorBoard Member Sep 13, 2006 9%
Eileen E Duffy Individual Corporate DirectorBoard Member Jun 19, 1995 9%
Rebecca P Reitz Individual Corporate DirectorBoard Member Aug 20, 2018
Jennifer Hardy Individual W-2 Managing EmployeeCfo Jan 9, 2023
April S Long Individual Corporate DirectorBoard Member Aug 20, 2018

Practitioners & affiliated clinicians

Practitioners 27

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.

View all 27

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": "1700099512",
    "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": "8920 OTTERBURN RD",
            "city": "AMELIA COURT HOUSE",
            "state": "VA",
            "postal_code": "230024854",
            "telephone_number": "804-561-5150",
            "fax_number": "804-561-6643"
        }
    ],
    "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": null,
            "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": "010192862",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Amelia Healthcare Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Amelia Court House, VA

Sources for this page

Verify at the official NPI Registry.