Healthcare Provider Details

I. General information

NPI: 1508883935
Provider Name (Legal Business Name): VETERANS ADMINISTRATION MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

IV. Provider business mailing address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone: 901-523-8990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number2028
License Number StateTN

VIII. Authorized Official

Name: MRS. DIANE LYNN SULLIVAN
Title or Position: PHYSICAL THERAPIST ASSISTANT
Credential:
Phone: 901-523-8990