Provider Demographics
NPI:1912340365
Name:RICHARD L. ROUDEBUSH VA MEDICAL CENTER
Entity type:Organization
Organization Name:RICHARD L. ROUDEBUSH VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RRT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HARLAN
Authorized Official - Suffix:
Authorized Official - Credentials:RRT/CRTT
Authorized Official - Phone:317-448-0843
Mailing Address - Street 1:4601 E CENTENNIAL AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-2610
Mailing Address - Country:US
Mailing Address - Phone:317-448-0843
Mailing Address - Fax:
Practice Address - Street 1:4601 E CENTENNIAL AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-2610
Practice Address - Country:US
Practice Address - Phone:317-448-0843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN30006732A286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital