Provider Demographics
NPI:1720116684
Name:FAYETTEVILLEVAMC
Entity Type:Organization
Organization Name:FAYETTEVILLEVAMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF LTC
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBARRO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEMMARAJU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-488-2120
Mailing Address - Street 1:9 PULLEY PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2436
Mailing Address - Country:US
Mailing Address - Phone:919-493-7654
Mailing Address - Fax:919-489-6588
Practice Address - Street 1:2300 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3856
Practice Address - Country:US
Practice Address - Phone:910-488-2120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital