Provider Demographics
NPI:1568634608
Name:VA MEDICAL CENTER
Entity Type:Organization
Organization Name:VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:VAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MT(ASCP)
Authorized Official - Phone:618-993-4113
Mailing Address - Street 1:2401 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1188
Mailing Address - Country:US
Mailing Address - Phone:618-993-4113
Mailing Address - Fax:618-998-5665
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-993-4113
Practice Address - Fax:618-998-5665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory