# PETERSBURG HOSPITAL COMPANY LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Southside Regional Medical Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1770556862
- **Authorized official:** PAULA M LALOR (DIRECTOR/DELEGATED OFFICIAL)
- **Authorized official phone:** (615) 925-4565

## Contact information

- **Practice address:** 200 MEDICAL PARK BLVD, PETERSBURG, VA 23805
- **Practice address phone:** (804) 765-5000
- **Practice address fax:** (804) 765-5962
- **Mailing address:** PO BOX 501128, SAINT LOUIS, MO 63150-1128

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | H1905 | VA | Yes |

## Other

- **Enumeration date:** 02/09/2006
- **Last updated:** 08/03/2017

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 442492 | BCBS | — |
| 05 | — | 4451697 | — | VA |