Healthcare Provider Details

I. General information

NPI: 1336589993
Provider Name (Legal Business Name): USAMEDDAC-JAPAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BG SAMS AHC, USAMEDDAC-JAPAN MCJA-PM, UNIT 45011
APO AP
96343-5011
US

IV. Provider business mailing address

BG SAMS AHC, USAMEDDAC-JAPAN MCJA-PM, UNIT 45011
APO AP
96343-5011
US

V. Phone/Fax

Practice location:
  • Phone: 315-263-5050
  • Fax: 315-263-4100
Mailing address:
  • Phone: 315-263-5050
  • Fax: 315-263-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1103X
TaxonomyMilitary Ambulatory Procedure Visits Operational (Transportable) Clinic/Center
License Number0001227332
License Number StateVA

VIII. Authorized Official

Name: DR. MICHAEL BRUMAGE
Title or Position: DEPUTY CHIEF OF CLINICAL SERVICES
Credential: MD
Phone: 315-263-4606