Basic Information
| Provider Information | |||||||||
| NPI: | 1538272828 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN D. DINGELL VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4646 JOHN R | ||||||||
| Address2: | PSYCHOLOGY SECTION (11MH-PS) | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
| FaxNumber: | 3135761091 | ||||||||
| Practice Location | |||||||||
| Address1: | 4646 JOHN R ST | ||||||||
| Address2: | PSYCHOLOGY SECTION (11MH-PS) | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | AXELROD | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 3135761000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | 6301007688 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | VA |
No ID Information.