Provider Demographics
NPI:1821535121
Name:PROVIDENCE VA MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-273-7100
Mailing Address - Street 1:830 CHALKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4734
Mailing Address - Country:US
Mailing Address - Phone:401-273-7100
Mailing Address - Fax:
Practice Address - Street 1:830 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4734
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital