MEDICARE: GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1100X	Military/U.S. Coast Guard Outpatient Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1225083249	OTHER		PARENT NPI

General Provider Information

NPI Number	:	1366812091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL

Provider Business Mailing Address
First Line	:	4430 MISSOURI AVE
Second Line	:	ATTN MCXP RMD UB BOX 1242
City	:	FORT LEONARD WOOD
State	:	MO
Zip	:	65473-9098
Country	:	US
Telephone Number	:	573-596-0494
Fax Number	:

Provider Business Practice Location Address
First Line	:	7621 BIG PINEY RD
Second Line	:
City	:	FORT LEONARD WOOD
State	:	MO
Zip	:	65473-1572
Country	:	US
Telephone Number	:	573-596-5408
Fax Number	:

Authorized Official
Title or Position	:	UBO MANAGER
Name	:	CRAIG PEEL
Credential	:
Telephone Number	:	573-596-0494

Provider Enumeration Date	:	10/07/2015
Last Update Date	:	10/07/2015

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