=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669881140
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAVAL HOSPITAL CAMP PENDLETON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2014
-----------------------------------------------------
Last Update Date | 08/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 MERCY CIRCLE ATTENTION: CODE 00QM
-----------------------------------------------------
City | CAMP PENDLETON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92055-5191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-725-4015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 MERCY CIRCLE ATTENTION: CODE 00QM
-----------------------------------------------------
City | CAMP PENDLETON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92055-5191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-725-4015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING OFFICER
-----------------------------------------------------
Name | TOM COLGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-725-8882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 286500000X
-----------------------------------------------------
Taxonomy Name | Military Hospital
-----------------------------------------------------
License Number | 829601
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------