Healthcare Provider Details

I. General information

NPI: 1003167354
Provider Name (Legal Business Name): DEPARTMENT OF VETERANS AFFAIRS CLEMENT J. ZABLOCKI MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-1000
US

IV. Provider business mailing address

741 W FRONT ST
APPLETON WI
54914-5468
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax:
Mailing address:
  • Phone: 920-450-1684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number176556-30
License Number StateWI

VIII. Authorized Official

Name: MS. KATRINA LIN BRUCKER
Title or Position: RN
Credential:
Phone: 920-450-1684