Basic Information
| Provider Information | |||||||||
| NPI: | 1558514729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RALPH H. JOHNSON VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 BEE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294015703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435775011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 BEE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294015703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435775011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2008 | ||||||||
| LastUpdateDate: | 10/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | MINTZER | ||||||||
| AuthorizedOfficialFirstName: | OLGA | ||||||||
| AuthorizedOfficialMiddleName: | BRAWMAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRINCIPAL INVESTIGATOR | ||||||||
| AuthorizedOfficialTelephone: | 8437401592 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | Y | Hospitals | Military Hospital |
No ID Information.