Basic Information
| Provider Information | |||||||||
| NPI: | 1922199066 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCDONALD ARMY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AHC MCDONALD-EUSTIS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 579 JEFFERSON AVE | ||||||||
| Address2: | ATTN UBO | ||||||||
| City: | FORT EUSTIS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 579 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | FORT EUSTIS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 04/10/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALBRIGHT | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | UBO REP | ||||||||
| AuthorizedOfficialTelephone: | 7573147755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient | 261QM1101X | Y | Ambulatory Health Care Facilities | Clinic/Center | Military and U.S. Coast Guard Ambulatory Procedure |
ID Information
| ID | Type | State | Issuer | Description | 007316 | 01 | VA | TRIGON PROVIDER NUMBER | OTHER | 266569 | 01 | VA | BLUE SHIELD PROVIDER NUMB | OTHER | 4830419 | 01 | NCPDP | OTHER |