Basic Information
| Provider Information | |||||||||
| NPI: | 1760795769 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOMACK ARMY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | FAYETTEVILLE MEDICAL HOME-BRAGG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2817 REILLY ST | ||||||||
| Address2: | MCXC-DBO-UB WAMC STOP A | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109076693 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2350 BENTRIDGE LN | ||||||||
| Address2: | WOODLAND BLDG | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283040586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109079262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2010 | ||||||||
| LastUpdateDate: | 02/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | BLACK | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | UBO MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9109078537 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WOMACK 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 |
ID Information
| ID | Type | State | Issuer | Description | 0294A | 01 | BCBS CMS 1500 PROVIDER ID | OTHER | 0465Y | 01 | BCBS PHARMACY ID | OTHER | 00539 | 01 | BCBS UB-04 PROVIDER ID | OTHER | 1740377423 | 01 | PARENT FACILITY NPI | OTHER |