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General NPI Number Information
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NPI Number | 1588653158
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Entity Type | Organization
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Legal Business Name | TROOP MEDICAL CLINIC #4
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Dates
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Enumeration Date | 10/17/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1061 HARMON AVE, STE 1D03 WINN ARMY COMMUNITY HOSPITAL
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City | FT. STEWART
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State | GA
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Zip | 31314-5611
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Country | US
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Telephone | 912-435-6933
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Fax |
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Provider Business Mailing Address
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Address Line | 92 BRITTANY CT
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City | RICHMOND HILL
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State | GA
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Zip | 31324-5184
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Country | US
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Telephone | 912-727-3073
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | MR. PATRICK MICHAEL PARKS
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Credential | PHYSICIAN ASSISTANT
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Telephone | 912-435-5179
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1100X
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Taxonomy Name | Military/U.S. Coast Guard Outpatient Clinic/Center
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License Number | 004529
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License Number State | GA
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