Healthcare Provider Details

I. General information

NPI: 1629066642
Provider Name (Legal Business Name): 18THMEDCOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121GENERAL HOSPITAL BOX709
APO AP
96205
US

IV. Provider business mailing address

121GENERAL HOSPITAL BOX709
APO AP
96205
US

V. Phone/Fax

Practice location:
  • Phone: 01182279166027
  • Fax:
Mailing address:
  • Phone: 01182279166027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number016541
License Number StateCT

VIII. Authorized Official

Name: DR. SOONHI SONG.
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 11-822-7917