Basic Information
| Provider Information | |||||||||
| NPI: | 1548672173 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EISENHOWER ARMY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | DOD FT BUCHANAN EPHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | EISENHOWER ARMY MEDICAL CENTER | ||||||||
| Address2: | C/O ATTN MCHF-PAD 300 W HOSPITAL ROAD | ||||||||
| City: | FT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877072319 | ||||||||
| FaxNumber: | 7877072591 | ||||||||
| Practice Location | |||||||||
| Address1: | RODRIGUEZ ARMY HEALTH CLINIC (RAHC) | ||||||||
| Address2: | BLDG 21 CHRISMAN RD. | ||||||||
| City: | FORT BUCHANAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009343400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877072319 | ||||||||
| FaxNumber: | 7877072591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2014 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X | Y | Suppliers | Military/U.S. Coast Guard Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2145989 | 01 | PK | OTHER |