Healthcare Provider Details

I. General information

NPI: 1497056535
Provider Name (Legal Business Name): VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2010
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21425 SPRING ST
UNION GROVE WI
53182-9707
US

IV. Provider business mailing address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-0001
US

V. Phone/Fax

Practice location:
  • Phone: 262-878-7024
  • Fax:
Mailing address:
  • Phone: 414-384-2000
  • Fax: 414-389-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number126683-121
License Number StateWI

VIII. Authorized Official

Name: MR. DAVID VAN THIEL
Title or Position: SOCIAL WORK EXECUTIVE
Credential: MSW
Phone: 414-384-2000