Healthcare Provider Details

I. General information

NPI: 1366536393
Provider Name (Legal Business Name): VETERANS ADMINISTRATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 MARKET AVE S
CANTON OH
44702-2165
US

IV. Provider business mailing address

2600 WESTDALE RD NW
CANTON OH
44708-1245
US

V. Phone/Fax

Practice location:
  • Phone: 330-489-4600
  • Fax:
Mailing address:
  • Phone: 330-477-4437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number35028791
License Number StateOH

VIII. Authorized Official

Name: DR. MIGUEL AVENIDO
Title or Position: RADIOLOGIST
Credential: M.D.
Phone: 330-489-4600