Provider Demographics
NPI:1558414987
Name:MADISON VAMC
Entity Type:Organization
Organization Name:MADISON VAMC
Other - Org Name:FREEPORT VA CBOC
Other - Org Type:Other Name
Authorized Official - Title/Position:NPI TEAM MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-382-2579
Mailing Address - Street 1:PO BOX 5117
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-0117
Mailing Address - Country:US
Mailing Address - Phone:608-821-7200
Mailing Address - Fax:
Practice Address - Street 1:750 KIWANIS DR
Practice Address - Street 2:SUITE 250
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-7119
Practice Address - Country:US
Practice Address - Phone:608-821-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA