Basic Information
| Provider Information | |||||||||
| NPI: | 1831212927 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALEDA E LUTZ VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 WEISS ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894972500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 WEISS ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894972500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 11/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | BRUNT | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2488408098 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101013443 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.