Basic Information
| Provider Information | |||||||||
| NPI: | 1093170730 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | G. V. SONNY MONTGOMERY VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E WOODROW WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
| FaxNumber: | 6013684089 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E WOODROW WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
| FaxNumber: | 6013684089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2015 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | BURNETT | ||||||||
| AuthorizedOfficialFirstName: | ANDREE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OF PRIMARY CARE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6013624471 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2865M2000X | 901359 | MS | Y | Hospitals | Military Hospital | Military General Acute Care Hospital |
No ID Information.