Basic Information
| Provider Information | |||||||||
| NPI: | 1427131432 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EISENHOWER ARMY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CONNELLY HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W HOSPITAL RD BLDG W | ||||||||
| Address2: | ATTN MCHF-PAD | ||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067871125 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 29709 B STREET | ||||||||
| Address2: | |||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067875811 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 01/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | PRIMOS | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | UBO MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7067877204 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EISENHOWER ARMY MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X | N | Suppliers | Military/U.S. Coast Guard Pharmacy | 261QM1100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
ID Information
| ID | Type | State | Issuer | Description | 1578660742 | 01 | PARENT MTF NPI | OTHER |