MEDICARE: EVANS 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	1497795702	OTHER		PARENT NPI

General Provider Information

NPI Number	:	1336355056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVANS ARMY COMMUNITY HOSPITAL

Provider Business Mailing Address
First Line	:	1650 COCHRANE CIR
Second Line	:	ATTN THIRD PARTY OFFICE
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4603
Country	:	US
Telephone Number	:	719-503-7045
Fax Number	:

Provider Business Practice Location Address
First Line	:	6911 TITUS BLVD
Second Line	:	BLDG 2353 WARRIOR FAMILY MEDICINE CLINIC
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4429
Country	:	US
Telephone Number	:	719-526-9277
Fax Number	:

Authorized Official
Title or Position	:	UBO MANAGER
Name	:	ELIZABETH BURLINGAME
Credential	:
Telephone Number	:	719-526-7291

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	11/17/2015

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