=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538272828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN D. DINGELL VA MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4646 JOHN R ST PSYCHOLOGY SECTION (11MH-PS)
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-1916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-576-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4646 JOHN R PSYCHOLOGY SECTION (11MH-PS)
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-1916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-576-1000
-----------------------------------------------------
Fax | 313-576-1091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. BRADLEY N. AXELROD
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 313-576-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QV0200X
-----------------------------------------------------
Taxonomy Name | VA Clinic/Center
-----------------------------------------------------
License Number | 6301007688
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------