Healthcare Provider Details

I. General information

NPI: 1104140425
Provider Name (Legal Business Name): RALPH JOHNSON VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST
CHARLESTON SC
29401-5703
US

IV. Provider business mailing address

336 PRESIDENT ST
CHARLESTON SC
29403-4314
US

V. Phone/Fax

Practice location:
  • Phone: 843-577-5011
  • Fax:
Mailing address:
  • Phone: 843-718-2161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number3570
License Number StateSC

VIII. Authorized Official

Name: MRS. KRISTY CARTER ANDERSON
Title or Position: ADULT NURSE PRACTITIONER
Credential: NURSE PRACTITIONER
Phone: 843-718-2161