Basic Information
| Provider Information | |||||||||
| NPI: | 1841216983 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WJB DORN VETERAN ADMINISTRATION MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 324 SPRING POINT DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292298940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038658715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 324 SPRING POINT DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292298940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037764000 | ||||||||
| FaxNumber: | 8036956772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOTROUS | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, ANATOMICAL PATHOLOGY | ||||||||
| AuthorizedOfficialTelephone: | 8037764000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.