Basic Information
Provider Information | |||||||||
NPI: | 1942386628 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WOMACK ARMY MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WAMC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2817 REILLY ST | ||||||||
Address2: | MCXC-DBO-UB WAMC STOP A | ||||||||
City: | FORT BRAGG | ||||||||
State: | NC | ||||||||
PostalCode: | 283107301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9109078537 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2817 REILLY ST | ||||||||
Address2: |   | ||||||||
City: | FORT BRAGG | ||||||||
State: | NC | ||||||||
PostalCode: | 283107301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9109079262 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/27/2006 | ||||||||
LastUpdateDate: | 02/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLACK | ||||||||
AuthorizedOfficialFirstName: | BARBARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | UBO MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9109078537 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1101X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Military and U.S. Coast Guard Ambulatory Procedure | 261QM1100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient | 332000000X |   |   | N |   | Suppliers | Military/U.S. Coast Guard Pharmacy |   | 341800000X |   |   | N |   | Transportation Services | Military/U.S. Coast Guard Transport |   | 2865M2000X |   |   | Y |   | Hospitals | Military Hospital | Military General Acute Care Hospital |
ID Information
ID | Type | State | Issuer | Description | 00539 | 01 | NC | BCBS UB 92 | OTHER | 0294A | 01 | NC | BCBS CMS 1500 | OTHER | 0465Y | 01 | NC | BCBS PHARMACY | OTHER |