MEDICARE: U.S. COAST GUARD ISC HONOLULU

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

General Provider Information

NPI Number	:	1316029259
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	U.S. COAST GUARD ISC HONOLULU

Provider Business Mailing Address
First Line	:	400 SAND ISLAND PKWY
Second Line	:	HEALTH SERVICES DIVISION
City	:	HONOLULU
State	:	HI
Zip	:	96819-4326
Country	:	US
Telephone Number	:	808-842-2930
Fax Number	:	808-842-2956

Provider Business Practice Location Address
First Line	:	400 SAND ISLAND PKWY
Second Line	:	HEALTH SERVICES DIVISION
City	:	HONOLULU
State	:	HI
Zip	:	96819-4326
Country	:	US
Telephone Number	:	808-842-2930
Fax Number	:	808-842-2956

Authorized Official
Title or Position	:	CLINIC ADMINISTRATOR
Name	:	MARC A. BUTLER
Credential	:
Telephone Number	:	808-842-2927

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	08/22/2020

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