Healthcare Provider Details

I. General information

NPI: 1295049773
Provider Name (Legal Business Name): UNITED STATES ARMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HOSPITAL RD
FORT GORDON GA
30905-5741
US

IV. Provider business mailing address

205 SARAH CREEK CT
MARTINEZ GA
30907-1223
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-2324
  • Fax:
Mailing address:
  • Phone: 785-817-1930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2865M2000X
TaxonomyMilitary General Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL QUINN
Title or Position: INTERNAL MEDICINE PROGRAM DIRECTOR
Credential: MD
Phone: 706-787-0674