Basic Information
| Provider Information | |||||||||
| NPI: | 1265682991 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF VETERANS AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 BEE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294015703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435775011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 BEE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294015703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435775011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 09/30/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MYRICK | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | HUGH | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH SERVICE LINE SUPERVIS | ||||||||
| AuthorizedOfficialTelephone: | 8435775011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | 3578 | SC | Y | Hospitals | Special Hospital |
No ID Information.