Healthcare Provider Details

I. General information

NPI: 1114128832
Provider Name (Legal Business Name): PHILADELPHIA VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8TH AND ALABAMA ST BUILDING 5437
FORT DIX NJ
08640
US

IV. Provider business mailing address

834 CHESTNUT ST APPARTMENT 732
PHILADELPHIA PA
19107-5127
US

V. Phone/Fax

Practice location:
  • Phone: 609-562-2999
  • Fax:
Mailing address:
  • Phone: 215-840-4223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number25MB08244700
License Number StateNJ

VIII. Authorized Official

Name: DR. MICHAEL GLIATTO
Title or Position: HIRING OFFICER
Credential: M.D.
Phone: 215-823-4037