Healthcare Provider Details

I. General information

NPI: 1699918920
Provider Name (Legal Business Name): JOHN D DINGELL VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201-1916
US

IV. Provider business mailing address

4646 JOHN R ST
DETROIT MI
48201-1916
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-1000
  • Fax: 313-576-1091
Mailing address:
  • Phone: 313-576-1000
  • Fax: 313-576-1091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number4801080039
License Number StateMI

VIII. Authorized Official

Name: MRS. BETH ANN SACKS
Title or Position: SUICIDE PREVENTION CASE MANAGER
Credential: LMSW
Phone: 313-576-1000