Healthcare Provider Details

I. General information

NPI: 1093170730
Provider Name (Legal Business Name): G. V. SONNY MONTGOMERY VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
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: 601-362-4471
  • Fax: 601-368-4089
Mailing address:
  • Phone: 601-362-4471
  • Fax: 601-368-4089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number901359
License Number StateMS

VIII. Authorized Official

Name: DR. ANDREE BURNETT
Title or Position: CHIEF OF PRIMARY CARE SERVICES
Credential: M.D.
Phone: 601-362-4471