Healthcare Provider Details

I. General information

NPI: 1902002462
Provider Name (Legal Business Name): MONCRIEF ARMY COMMUNITY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 WASHINGTON ROAD
FORT JACKSON SC
29207
US

IV. Provider business mailing address

4500 STUART ST BOX 497
FORT JACKSON SC
29207-5720
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-2021
  • Fax:
Mailing address:
  • Phone: 803-751-0472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: WILLIE WARREN
Title or Position: CHIEF, UBO
Credential:
Phone: 803-751-0472