MEDICARE: US ARMY HEALTH CLINIC

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	261QM1101X	Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center	70101705	WI
2	261QM1100X	Military/U.S. Coast Guard Outpatient Clinic/Center	343143	WI

General Provider Information

NPI Number	:	1952854648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	US ARMY HEALTH CLINIC

Provider Business Mailing Address
First Line	:	BLDG 2669 WEST REGIMENTAL ROAD
Second Line	:
City	:	FT MCCOY
State	:	WI
Zip	:	54656-5229
Country	:	US
Telephone Number	:	608-388-3025
Fax Number	:	608-388-4818

Provider Business Practice Location Address
First Line	:	BLDG 2669 WEST REGIMENTAL ROAD
Second Line	:
City	:	FT MCCOY
State	:	WI
Zip	:	54656-5229
Country	:	US
Telephone Number	:	608-388-3025
Fax Number	:	608-388-4818

Authorized Official
Title or Position	:	NURSE ASSISTANT
Name	:	MR. JESSE C KOLLASCH-ROBERTS
Credential	:
Telephone Number	:	608-388-3025

Provider Enumeration Date	:	07/28/2016
Last Update Date	:	07/28/2016

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Directions to “US ARMY HEALTH CLINIC ” Practice Location

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