Provider Demographics
NPI:1336175793
Name:VA MEDICAL CENTER
Entity Type:Organization
Organization Name:VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM SUPPORT ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:JAYME
Authorized Official - Middle Name:S
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-845-3007
Mailing Address - Street 1:17194 CAMERON DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-3211
Mailing Address - Country:US
Mailing Address - Phone:248-449-2644
Mailing Address - Fax:
Practice Address - Street 1:2215 FULLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2303
Practice Address - Country:US
Practice Address - Phone:734-761-7926
Practice Address - Fax:734-769-7410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060642282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10890224OtherCAQH
MI10890224OtherCAQH