Basic Information
| Provider Information | |||||||||
| NPI: | 1437182771 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VA ANNARBOR HEALTHCARE SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEPARTMENT OF VETERAN AFFAIRS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15908 CRYSTAL DOWNS E | ||||||||
| Address2: | |||||||||
| City: | NORTHVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481688481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347370516 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2215 FULLER RD | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481052335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347697100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | POUSAK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | PATRICIA | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 7347697100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN,NP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 4704190831 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.