=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093170730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | G. V. SONNY MONTGOMERY VA MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2015
-----------------------------------------------------
Last Update Date | 12/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 E WOODROW WILSON AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-5116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-362-4471
-----------------------------------------------------
Fax | 601-368-4089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 E WOODROW WILSON AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-5116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-362-4471
-----------------------------------------------------
Fax | 601-368-4089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OF PRIMARY CARE SERVICES
-----------------------------------------------------
Name | DR. ANDREE BURNETT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 601-362-4471
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2865M2000X
-----------------------------------------------------
Taxonomy Name | Military General Acute Care Hospital
-----------------------------------------------------
License Number | 901359
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------