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General NPI Number Information
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NPI Number | 1245325356
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Entity Type | Organization
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Legal Business Name | VA MEDICAL CENTER, PHILADELPHIA PA
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3900 WOODLAND AVENUE PATHOLOGY & LAB. MED. (113) - VAMC CLIN. ADD. BLDG.
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City | PHILADELPHIA
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State | PA
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Zip | 19104-4551
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Country | US
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Telephone | 215-823-5182
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Fax | 215-823-4271
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Provider Business Mailing Address
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Address Line | 715 N. ITHAN AVENUE
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City | ROSEMONT
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State | PA
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Zip | 19010-1729
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Country | US
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Telephone | 215-823-5182
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Fax | 215-823-4271
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. MICHAEL J SULLIVAN
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Credential |
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Telephone | 215-823-5857
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | MD-036835L
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License Number State | PA
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