Basic Information
| Provider Information | |||||||||
| NPI: | 1730493008 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLANCHFIELD ARMY COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CBPCC 2-FT. CAMPBELL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | UNIFORM BUSINESS OFFICE | ||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988286 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | CBPCC 2-FT. CAMPBELL-HOPKINSVILLE LOCATION | ||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709560606 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2010 | ||||||||
| LastUpdateDate: | 01/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | O'NEAL | ||||||||
| AuthorizedOfficialFirstName: | LIZA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | C, PAD | ||||||||
| AuthorizedOfficialTelephone: | 2707988491 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BLANCHFIELD 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 | 1417044702 | 01 | PARENT BILLING NPI | OTHER |