Basic Information
| Provider Information | |||||||||
| NPI: | 1306922968 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 WALDEN DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483011149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488553982 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2215 FULLER RD | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481052335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347697100 | ||||||||
| FaxNumber: | 7347697172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 02/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | JAYME | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM SUPPORT ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 7348453007 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | 4301036985 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | VA |
ID Information
| ID | Type | State | Issuer | Description | BK1483724 | 01 | MI | DEA | OTHER |