Basic Information
| Provider Information | |||||||||
| NPI: | 1811192594 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GUTHRIE AHC | ||||||||
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| OtherOrganizationName: | USADC CLARK HALL INPROC C-DRUM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11050 MOUNT BELVEDERE BLVD | ||||||||
| Address2: | UBO | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157724033 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10720 MT BELVEDERE BLVD | ||||||||
| Address2: | SUITE A1-102 | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157722778 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | DRAPER | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACTING UBO MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3157721755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GUTHRIE AHC | ||||||||
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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.