Provider Demographics
NPI:1811165905
Name:WJB DORN VA HOSPITAL
Entity type:Organization
Organization Name:WJB DORN VA HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PATHOLOGIST AP CLINICAL DIR.
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTROUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-776-4000
Mailing Address - Street 1:6439 GARNERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1638
Mailing Address - Country:US
Mailing Address - Phone:803-865-8715
Mailing Address - Fax:803-695-6772
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-865-8715
Practice Address - Fax:803-695-6772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21332282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital