Healthcare Provider Details

I. General information

NPI: 1255362729
Provider Name (Legal Business Name): ATLANTA VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD ATLANTA VA
DECATUR GA
30033-4004
US

IV. Provider business mailing address

4366 IDLEWOOD LN
TUCKER GA
30084-6437
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 770-712-8249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License NumberRN 096164-NP
License Number StateGA

VIII. Authorized Official

Name: MR. ROBERT RAY ALEXANDER
Title or Position: NURSE PRACTIONER
Credential: APRN
Phone: 404-321-6111