=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225184088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EISENHOWER ARMY MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 W HOSPITAL ROAD EISENHOWER ARMY MEDICAL CENTER CREDENTIALS
-----------------------------------------------------
City | FORT GORDON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30905-5650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-787-2720
-----------------------------------------------------
Fax | 706-787-8176
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 W HOSPITAL ROAD EISENHOWER ARMY MEDICAL CENTER
-----------------------------------------------------
City | FORT GORDON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30905-5650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-787-2720
-----------------------------------------------------
Fax | 706-787-8176
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF, SOCIAL WORK SERVICE
-----------------------------------------------------
Name | YVONNE LOVENIA TUCKER-HARRIS
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 706-787-6624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 286500000X
-----------------------------------------------------
Taxonomy Name | Military Hospital
-----------------------------------------------------
License Number | 12359
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------