Healthcare Provider Details

I. General information

NPI: 1497930184
Provider Name (Legal Business Name): DEPARTMENT OF VETERANS AFFAIR G.V. (SONNY) MONTGOMERY VA MEDICAL CENTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2008
Last Update Date: 01/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5942 WESTMORE DR
JACKSON MS
39206-2209
US

IV. Provider business mailing address

5942 WESTMORE DR
JACKSON MS
39206-2209
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-1739
  • Fax:
Mailing address:
  • Phone: 601-366-1739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberP321453
License Number StateMS

VIII. Authorized Official

Name: MRS. AMY WHEAT
Title or Position: NURSE RECRUITER
Credential: RN, BSN
Phone: 601-368-3873