Healthcare Provider Details

I. General information

NPI: 1306874219
Provider Name (Legal Business Name): ATLANTA VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

630 CREEKVIEW BLVD
COVINGTON GA
30016-3085
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax: 404-329-4632
Mailing address:
  • Phone: 770-385-7377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberR109830
License Number StateGA

VIII. Authorized Official

Name: MS. MELODYE MARGUERITE JACOBS
Title or Position: CHARGE NURSE
Credential: RN
Phone: 404-321-6111