Healthcare Provider Details

I. General information

NPI: 1871992131
Provider Name (Legal Business Name): G.V. MONTGOMERY VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

IV. Provider business mailing address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

V. Phone/Fax

Practice location:
  • Phone: 601-368-4498
  • Fax:
Mailing address:
  • Phone: 601-368-4498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberR897708
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberP326213
License Number StateMS

VIII. Authorized Official

Name: AUDREY D YOUNGBLOOD
Title or Position: RN
Credential: RN
Phone: 601-320-8949