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General NPI Number Information
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NPI Number | 1265508287
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Entity Type | Organization
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Legal Business Name | VA JACKSON
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 07/10/2007
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Provider Practice Location Address
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Address Line | 1500 E WOODROW WILSON AVE
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City | JACKSON
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State | MS
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Zip | 39216-5116
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Country | US
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Telephone | 601-364-1359
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Fax |
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Provider Business Mailing Address
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Address Line | 158 FRENCH BR
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City | MADISON
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State | MS
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Zip | 39110-8173
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | RADIOLOGY
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Name | WILLIAM TIDWELL
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Credential |
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Telephone | 601-898-4777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 286500000X
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Taxonomy Name | Military Hospital
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License Number |
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License Number State |
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