MEDICARE: UNITED STATES MARINE CORPS

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	286500000X	Military Hospital

General Provider Information

NPI Number	:	1497048151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNITED STATES MARINE CORPS

Provider Business Mailing Address
First Line	:	2488 GRAND CONCOURSE RM 204
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10458-5207
Country	:	US
Telephone Number	:	718-938-0696
Fax Number	:	718-367-6212

Provider Business Practice Location Address
First Line	:	2488 GRAND CONCOURSE RM 204
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10458-5207
Country	:	US
Telephone Number	:	718-938-0696
Fax Number	:	718-367-6212

Authorized Official
Title or Position	:	MILITARY
Name	:	MR. ERWIN MEMBRENO
Credential	:
Telephone Number	:	718-938-0696

Provider Enumeration Date	:	05/26/2011
Last Update Date	:	05/26/2011

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