Provider Demographics
NPI:1871992131
Name:G.V. MONTGOMERY VA MEDICAL CENTER
Entity type:Organization
Organization Name:G.V. MONTGOMERY VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:YOUNGBLOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:601-320-8949
Mailing Address - Street 1:1500 E WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5116
Mailing Address - Country:US
Mailing Address - Phone:601-368-4498
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-368-4498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR897708282N00000X
MSP326213310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility