Provider Demographics
NPI:1114133923
Name:GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL
Other - Org Name:USA OCCUP HLTH CLIN-GOODFELLOW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:UBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-596-0494
Mailing Address - Street 1:4430 MISSOURI AVE
Mailing Address - Street 2:BOX 1242
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-9098
Mailing Address - Country:US
Mailing Address - Phone:573-596-0494
Mailing Address - Fax:
Practice Address - Street 1:4300 GOODFELLOW BLVD
Practice Address - Street 2:GOODFELLOW COMPLEX BLDG 103D
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63120-1703
Practice Address - Country:US
Practice Address - Phone:573-596-0035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-16
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN
OTH000Medicare UPIN