Healthcare Provider Details

I. General information

NPI: 1508061292
Provider Name (Legal Business Name): JEREMY S COVELL IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3RD MED BN 3RD FSSG BRAVO CO UNIT 38448
FPO AP
96604
JP

IV. Provider business mailing address

PSC 567 BOX 6634
FPO AP
96384
JP

V. Phone/Fax

Practice location:
  • Phone: 6234960
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: