Basic Information
| Provider Information | |||||||||
| NPI: | 1124232467 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCDONALD ARMY HEALTH CENTER | ||||||||
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| OtherOrganizationName: | AHC-STORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 579 JEFFERSON AVE | ||||||||
| Address2: | ATTN UBO | ||||||||
| City: | FORT EUSTIS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236041526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 649 NEW GUINEA RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234518124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574227822 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | ALBRIGHT | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | UBO REP | ||||||||
| AuthorizedOfficialTelephone: | 7573147755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCDONALD ARMY HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
ID Information
| ID | Type | State | Issuer | Description | 1922199066 | 01 | PARENT FACILITY NPI | OTHER |