Basic Information
| Provider Information | |||||||||
| NPI: | 1225370711 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN ANTONIO MILITARY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BEHAVIORAL MEDICINE-NEUROPSYCHOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3851 ROGER BROOKE DR | ||||||||
| Address2: | MCHE-QD (CREDS), | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109163710 | ||||||||
| FaxNumber: | 2109165102 | ||||||||
| Practice Location | |||||||||
| Address1: | 3851 ROGER BROOKE DR | ||||||||
| Address2: | MCHE-QD (CREDS), | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109163710 | ||||||||
| FaxNumber: | 2109165102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2013 | ||||||||
| LastUpdateDate: | 03/22/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORGAN | ||||||||
| AuthorizedOfficialFirstName: | ETHEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALS COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2109163710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | 35165 | TX | Y | Hospitals | Military Hospital |
No ID Information.