Basic Information
| Provider Information | |||||||||
| NPI: | 1750584363 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EISENHOWER ARMY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | USADC CAMP SHELBY 6 | ||||||||
| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 14TH ST | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394070001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015582575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2007 | ||||||||
| LastUpdateDate: | 01/29/2013 | ||||||||
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| AuthorizedOfficialLastName: | PRIMOS | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
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| 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 | 261QM1100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
No ID Information.