Healthcare Provider Details

I. General information

NPI: 1427131432
Provider Name (Legal Business Name): EISENHOWER ARMY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29709 B STREET
FORT GORDON GA
30905-5741
US

IV. Provider business mailing address

300 W HOSPITAL RD BLDG W ATTN MCHF-PAD
FORT GORDON GA
30905-5741
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-5811
  • Fax:
Mailing address:
  • Phone: 706-787-1125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARVIN PRIMOS
Title or Position: UBO MANAGER
Credential:
Phone: 706-787-7204