Provider Demographics
NPI:1497702591
Name:US ARMY HEALTH CLINIC
Entity Type:Organization
Organization Name:US ARMY HEALTH CLINIC
Other - Org Name:OHC DUGWAY PROVING GROUND
Other - Org Type:Other Name
Authorized Official - Title/Position:UBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BURLINGAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-526-7291
Mailing Address - Street 1:5116 KISTER AVE
Mailing Address - Street 2:ATTN: MSA OFFICE
Mailing Address - City:DUGWAY
Mailing Address - State:UT
Mailing Address - Zip Code:84022-1097
Mailing Address - Country:US
Mailing Address - Phone:435-831-3313
Mailing Address - Fax:435-831-3360
Practice Address - Street 1:5116 KISTER AVE
Practice Address - Street 2:RM #119
Practice Address - City:DUGWAY
Practice Address - State:UT
Practice Address - Zip Code:84022-1097
Practice Address - Country:US
Practice Address - Phone:435-831-3313
Practice Address - Fax:435-831-3360
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVANS ARMY COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2015-11-17
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
AN2598588OtherMEDCO
4609307OtherNCPDP
OTH000Medicare UPIN
4609307OtherNCPDP