Provider Demographics
NPI:1003167354
Name:DEPARTMENT OF VETERANS AFFAIRS CLEMENT J. ZABLOCKI MEDICAL CENTER
Entity Type:Organization
Organization Name:DEPARTMENT OF VETERANS AFFAIRS CLEMENT J. ZABLOCKI MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MS
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:LIN
Authorized Official - Last Name:BRUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-450-1684
Mailing Address - Street 1:741 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-5468
Mailing Address - Country:US
Mailing Address - Phone:920-450-1684
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-1000
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI176556-30282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital