Basic Information
| Provider Information | |||||||||
| NPI: | 1275747149 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KELLER ARMY COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MILLS TROOP CLINIC-FT. DIX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 5631 BALTIMORE ST | ||||||||
| Address2: | |||||||||
| City: | FORT DIX | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086405440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459384034 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 12/20/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TUFFY | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | UBO MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8459388239 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KELLER ARMY COMMUNITY HOSPITAL | ||||||||
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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 | 1528161916 | 01 | PARENT FACILITY NPI | OTHER |