Basic Information
| Provider Information | |||||||||
| NPI: | 1306874219 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTA VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 CREEKVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300163085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703857377 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1670 CLAIRMONT RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
| FaxNumber: | 4043294632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACOBS | ||||||||
| AuthorizedOfficialFirstName: | MELODYE | ||||||||
| AuthorizedOfficialMiddleName: | MARGUERITE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHARGE NURSE | ||||||||
| AuthorizedOfficialTelephone: | 4043216111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP2201X | R109830 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Ambulatory Care |
No ID Information.