Healthcare Provider Details

I. General information

NPI: 1114391802
Provider Name (Legal Business Name): MONCRIEF ARMY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 STUART ST
COLUMBIA SC
29207-5700
US

IV. Provider business mailing address

4500 STUART ST
COLUMBIA SC
29207-5700
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-2253
  • Fax:
Mailing address:
  • Phone: 803-751-2253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number7985
License Number StateSC

VIII. Authorized Official

Name: MRS. LATOYA M WANSER
Title or Position: CREDENTIALS MANAGER
Credential:
Phone: 803-751-5688