MEDICARE: MARTIN ARMY COMMUNITY HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1100X	Military/U.S. Coast Guard Outpatient Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1194730846	OTHER		PARENT BILLING NPI

General Provider Information

NPI Number	:	1053624130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARTIN ARMY COMMUNITY HOSPITAL

Provider Business Mailing Address
First Line	:	6600 VAN AALST BLVD BLDG 9250
Second Line	:	ATTN TREASURY OFFICE MCXB-PP
City	:	FORT BENNING
State	:	GA
Zip	:	31905-2102
Country	:	US
Telephone Number	:	706-544-5724
Fax Number	:

Provider Business Practice Location Address
First Line	:	6976 OLD CUSSETA RD
Second Line	:	HARMONY CHURCH
City	:	FORT BENNING
State	:	GA
Zip	:	31905-5431
Country	:	US
Telephone Number	:	706-544-3278
Fax Number	:

Authorized Official
Title or Position	:	UBO MANAGER
Name	:	KERTREDIA DAVIS
Credential	:	CCA, CPAR, CRCR
Telephone Number	:	762-408-0007

Provider Enumeration Date	:	07/19/2010
Last Update Date	:	01/20/2021

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