Basic Information
| Provider Information | |||||||||
| NPI: | 1194031583 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3851 ROGER BROOKE DR. | ||||||||
| Address2: | BAMC-MCHEQD (CREDS) | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782186200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109162460 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3851 ROGER BROOKE DR. | ||||||||
| Address2: | BAMC-MCHEQD (CREDS) | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782186200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109162460 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2010 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
| AuthorizedOfficialFirstName: | RAMONA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF, CREDENTIALS SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 2109162460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | 390200000X | TX | Y | Hospitals | Military Hospital |
ID Information
| ID | Type | State | Issuer | Description | 390200000X | 01 | TX | BAMC | OTHER |