Provider Demographics
NPI:1588653158
Name:TROOP MEDICAL CLINIC #4
Entity Type:Organization
Organization Name:TROOP MEDICAL CLINIC #4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:912-435-5179
Mailing Address - Street 1:92 BRITTANY CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-5184
Mailing Address - Country:US
Mailing Address - Phone:912-727-3073
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE, STE 1D03
Practice Address - Street 2:WINN ARMY COMMUNITY HOSPITAL
Practice Address - City:FT. STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5611
Practice Address - Country:US
Practice Address - Phone:912-435-6933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004529261QM1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient