Basic Information
| Provider Information | |||||||||
| NPI: | 1518127026 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DURHAM VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 508 FULTON ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277053875 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 508 FULTON ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277053875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192860411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | FAIRBANK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MIRECC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9192860411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.