Provider Demographics
NPI:1144298142
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:DISTRICT DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:757-727-1172
Mailing Address - Street 1:3130 VICTORIA BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23661-1544
Mailing Address - Country:US
Mailing Address - Phone:757-727-1172
Mailing Address - Fax:757-727-1185
Practice Address - Street 1:3130 VICTORIA BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23661-1544
Practice Address - Country:US
Practice Address - Phone:757-727-1172
Practice Address - Fax:757-727-1185
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-08
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004975014Medicaid
VA0036501Medicaid
VA47211OtherSENTARA HEALTH PROVIDER #
VA089265OtherANTHEM PROVIDER NUMBER
VA84962OtherVIRGINIA PREMIER PROVID #
VA0036501Medicaid
VAC08654Medicare PIN
VA600001921Medicare PIN