Provider Demographics
NPI:1306874219
Name:ATLANTA VA MEDICAL CENTER
Entity type:Organization
Organization Name:ATLANTA VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHARGE NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:MELODYE
Authorized Official - Middle Name:MARGUERITE
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:404-321-6111
Mailing Address - Street 1:630 CREEKVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-3085
Mailing Address - Country:US
Mailing Address - Phone:770-385-7377
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:404-329-4632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR109830163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory CareGroup - Multi-Specialty