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General NPI Number Information
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NPI Number | 1366423741
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Entity Type | Organization
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Legal Business Name | US ARMY
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Dates
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Enumeration Date | 11/11/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2200 BERGQUIST DR
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City | LACKLAND A F B
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State | TX
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Zip | 78236-9907
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Country | US
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Telephone | 210-292-0427
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Fax |
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Provider Business Mailing Address
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Address Line | 2200 BERGQUIST DR
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City | LACKLAND A F B
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State | TX
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Zip | 78236-9907
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Country | US
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Telephone | 210-292-0427
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Fax |
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Authorized Official
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Title or Position | CHIEF PEDIATRICS
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Name | TED CIESLACK
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Credential | MD
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Telephone | 210-916-0707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 286500000X
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Taxonomy Name | Military Hospital
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License Number | M1366
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License Number State | TX
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