Basic Information
| Provider Information | |||||||||
| NPI: | 1902259948 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVANS ARMY COMMUNITY HOSPITAL PEDIATRIC CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COCHRANE CIR | ||||||||
| Address2: | |||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267653 | ||||||||
| FaxNumber: | 7195267673 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 COCHRANE CIR | ||||||||
| Address2: | |||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267653 | ||||||||
| FaxNumber: | 7195267673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2016 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF, PEDIATRIC CLINIC | ||||||||
| AuthorizedOfficialTelephone: | 7195267653 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EVANS ARMY COMMUNITY HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.