=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811192594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUTHRIE AHC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2007
-----------------------------------------------------
Last Update Date | 03/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10720 MT BELVEDERE BLVD SUITE A1-102
-----------------------------------------------------
City | FORT DRUM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13602-5040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-772-2778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11050 MOUNT BELVEDERE BLVD UBO
-----------------------------------------------------
City | FORT DRUM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13602-5438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-772-4033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACTING UBO MANAGER
-----------------------------------------------------
Name | NANCY DRAPER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-772-1755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1100X
-----------------------------------------------------
Taxonomy Name | Military/U.S. Coast Guard Outpatient Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------