Provider Demographics
NPI:1164679601
Name:MARTIN ARMY COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:MARTIN ARMY COMMUNITY HOSPITAL
Other - Org Name:TMC EGLIN AFB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:UBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KERTREDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:762-408-0007
Mailing Address - Street 1:6600 VAN AALST BLVD BLDG 9250
Mailing Address - Street 2:ATTN TREASURY MCXB-PP
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:762-408-2273
Mailing Address - Fax:
Practice Address - Street 1:6069 WALKERS LN
Practice Address - Street 2:TMC 12 CAMP RUDDER
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-8505
Practice Address - Country:US
Practice Address - Phone:850-882-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTIN ARMY COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-27
Last Update Date:2021-01-20
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
1194730846OtherPARENT FACILITY NPI
VAD000Medicare UPIN
1194730846OtherPARENT FACILITY NPI