Provider Demographics
NPI:1164636320
Name:EISENHOWER ARMY MEDICAL CENTER
Entity Type:Organization
Organization Name:EISENHOWER ARMY MEDICAL CENTER
Other - Org Name:SOUTHCOM CLINIC-FT. GORDON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:UBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-787-7204
Mailing Address - Street 1:300 W HOSPITAL RD BLDG W
Mailing Address - Street 2:ATTN MCHF-PAD
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:706-787-1125
Mailing Address - Fax:
Practice Address - Street 1:3511 NW 91ST AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-1216
Practice Address - Country:US
Practice Address - Phone:305-437-1970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EISENHOWER ARMY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-09
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578660742OtherPARENT MTF NPI
1578660742OtherPARENT MTF NPI
VAD000Medicare UPIN