Provider Demographics
NPI:1376974303
Name:MADIGAN ARMY MEDICAL CTR
Entity Type:Organization
Organization Name:MADIGAN ARMY MEDICAL CTR
Other - Org Name:4/2 EBH CLINIC-JBLM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TPC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-968-6598
Mailing Address - Street 1:9040A JACKSON AVE
Mailing Address - Street 2:ATTN: MCHJ-CSA-U
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-6598
Mailing Address - Fax:
Practice Address - Street 1:3 RD DIVISION DR BLDG R3150
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-967-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADIGAN ARMY MEDICAL CTR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-02
Last Update Date:2015-04-13
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