Provider Demographics
NPI:1013014695
Name:SONNY MONTGOMERY V A M EDICAL CENTER
Entity Type:Organization
Organization Name:SONNY MONTGOMERY V A M EDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MSN NURSING
Authorized Official - Phone:601-362-4471
Mailing Address - Street 1:1973 HOUSTON RD
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MS
Mailing Address - Zip Code:39041-9387
Mailing Address - Country:US
Mailing Address - Phone:601-866-2429
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR725005281P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes281P00000XHospitalsChronic Disease Hospital