Provider Demographics
NPI:1477538361
Name:USCG AIR STATION PORT ANGELES MEDCIAL/DENTAL CLINIC
Entity Type:Organization
Organization Name:USCG AIR STATION PORT ANGELES MEDCIAL/DENTAL CLINIC
Other - Org Name:GERSHOWITZ CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR HEALTH SERVICES OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KINSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-417-5894
Mailing Address - Street 1:COMMANDANT USCG HQ (CG-1122)
Mailing Address - Street 2:2100 2ND STREET
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20593-0001
Mailing Address - Country:US
Mailing Address - Phone:202-267-0801
Mailing Address - Fax:
Practice Address - Street 1:COMMANDANT USCG HQ (CG-1122)
Practice Address - Street 2:2100 2ND STREET
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20593-0001
Practice Address - Country:US
Practice Address - Phone:202-267-0801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2010-08-18
Deactivation Date:2008-06-03
Deactivation Code:
Reactivation Date:2010-08-17
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient