Basic Information
| Provider Information | |||||||||
| NPI: | 1508883935 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VETERANS ADMINISTRATION MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1030 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9015238990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 2028 | TN | Y | Hospitals | General Acute Care Hospital |
No ID Information.