Healthcare Provider Details

I. General information

NPI: 1063288702
Provider Name (Legal Business Name): ATLANTA VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7709 LAMPHERE
DETROIT MI
48239-1082
US

IV. Provider business mailing address

7709 LAMPHERE
DETROIT MI
48239-1082
US

V. Phone/Fax

Practice location:
  • Phone: 313-300-9541
  • Fax:
Mailing address:
  • Phone: 313-300-9541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C1101X
TaxonomyCardiovascular-Interventional Technology Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: SHERRY LYNN WILLIAMS
Title or Position: CAT SCAN TECHNICIAN
Credential: RT(R)CT
Phone: 313-300-9541