Provider Demographics
NPI:1720172174
Name:VA HOSPITAL - MARION, IN
Entity Type:Organization
Organization Name:VA HOSPITAL - MARION, IN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTON
Authorized Official - Middle Name:N
Authorized Official - Last Name:KOJOUHAROV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-674-3321
Mailing Address - Street 1:979 E LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:IN
Mailing Address - Zip Code:46001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 EAST 38 STREET
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953
Practice Address - Country:US
Practice Address - Phone:888-838-6446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035651261QV0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA