Healthcare Provider Details

I. General information

NPI: 1841636149
Provider Name (Legal Business Name): ANN ARBOR VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

V. Phone/Fax

Practice location:
  • Phone: 734-845-3988
  • Fax:
Mailing address:
  • Phone: 734-845-3988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number4703111463
License Number StateMI

VIII. Authorized Official

Name: TYKISHA PHELAN
Title or Position: DEPENDENT CREDENTIALING COORDINATOR
Credential:
Phone: 734-845-3988