=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427131432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EISENHOWER ARMY MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 01/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29709 B STREET
-----------------------------------------------------
City | FORT GORDON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30905-5741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-787-5811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 W HOSPITAL RD BLDG W ATTN MCHF-PAD
-----------------------------------------------------
City | FORT GORDON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30905-5741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-787-1125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | UBO MANAGER
-----------------------------------------------------
Name | MARVIN PRIMOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-787-7204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332000000X
-----------------------------------------------------
Taxonomy Name | Military/U.S. Coast Guard Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1100X
-----------------------------------------------------
Taxonomy Name | Military/U.S. Coast Guard Outpatient Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------