MEDICARE: EISENHOWER ARMY MEDICAL CENTER

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	332000000X	Military/U.S. Coast Guard Pharmacy
2	261QM1100X	Military/U.S. Coast Guard Outpatient Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1578660742	OTHER		PARENT MTF NPI

General Provider Information

NPI Number	:	1770798316
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EISENHOWER ARMY MEDICAL CENTER

Provider Business Mailing Address
First Line	:	300 W HOSPITAL RD BLDG W
Second Line	:	ATTN MCHF-PAD
City	:	FORT GORDON
State	:	GA
Zip	:	30905-5741
Country	:	US
Telephone Number	:	706-787-1125
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 CHRISMAN RD
Second Line	:
City	:	FORT BUCHANAN
State	:	PR
Zip	:	00934-4519
Country	:	US
Telephone Number	:	706-787-5811
Fax Number	:

Authorized Official
Title or Position	:	UBO MANAGER
Name	:	MARVIN PRIMOS
Credential	:
Telephone Number	:	706-787-7204

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	01/29/2013

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