Basic Information
Provider Information | |||||||||
NPI: | 1124223235 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KELLER ARMY COMMUNITY HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | USADC WEST POINT MILLS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 900 WASHINGTON RD | ||||||||
Address2: | ATTN MCUD-RMD-UBO | ||||||||
City: | WEST POINT | ||||||||
State: | NY | ||||||||
PostalCode: | 109961109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8459388239 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5660 DOUGHBOY LOOP | ||||||||
Address2: |   | ||||||||
City: | FORT DIX | ||||||||
State: | NJ | ||||||||
PostalCode: | 08640 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8459384034 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2007 | ||||||||
LastUpdateDate: | 12/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TUFFY | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | UBO MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8459388239 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | KELLER ARMY COMMUNITY HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
No ID Information.