NPIMap

Organization Active NPI

Dominion Health Medical Assoc

  • Clinic/Center
  • South Boston, VA
National Provider Identifier
1760740625
Registry record updated Feb 10, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
License
0101251410 Issued in VA
Legal business name
DOMINION HEALTH MEDICAL ASSOC
Practice address
2206 Wilborn Ave
South Boston, VA 24592
Phone
(434) 517-8075
Fax
(434) 517-3887
NPI assigned
Apr 30, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 10, 2015

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

Authorized official

Name
Cecil Hazelwood
Title
Manager (SDHG)
Phone
(434) 517-3515

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 0101251410 VA Primary

Addresses

Primary practice location

2206 Wilborn Ave
South Boston, VA 24592

Mailing address

P.O. Box 860
South Boston, VA 24592
Phone (434) 517-3513

Other identifiers 1

IdentifierTypeStateIssuer
0101251410OtherVALICENSE

Other names 1

  • Sentara Halifax Neurology Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041206000840 VA Part B Supplier - Clinic/Group Practice 1254311558 Receives reassigned benefits from 91 practitioners
17 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: South Boston, VA

Other NPIs on the same Medicare enrollment 17

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

View all 17

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1335744000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1423526400000",
    "number": "1760740625",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P.O. BOX 860",
            "city": "SOUTH BOSTON",
            "state": "VA",
            "postal_code": "24592",
            "telephone_number": "434-517-3513",
            "fax_number": "434-517-3887"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2206 WILBORN AVE",
            "city": "SOUTH BOSTON",
            "state": "VA",
            "postal_code": "24592",
            "telephone_number": "434-517-8075",
            "fax_number": "434-517-3887"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DOMINION HEALTH MEDICAL ASSOC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-04-30",
        "last_updated": "2015-02-10",
        "status": "A",
        "authorized_official_last_name": "HAZELWOOD",
        "authorized_official_first_name": "CECIL",
        "authorized_official_title_or_position": "MANAGER (SDHG)",
        "authorized_official_telephone_number": "434-517-3515"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "VA",
            "license": "0101251410",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "0101251410",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sentara Halifax Neurology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in South Boston, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.