Provider Demographics
NPI:1760673032
Name:U.S. COAST GUARD
Entity Type:Organization
Organization Name:U.S. COAST GUARD
Other - Org Name:U.S. COAST GUARD ACADEMY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:SCHON
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-701-6736
Mailing Address - Street 1:15 MOHEGAN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-8100
Mailing Address - Country:US
Mailing Address - Phone:860-444-8402
Mailing Address - Fax:
Practice Address - Street 1:15 MOHEGAN AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-8100
Practice Address - Country:US
Practice Address - Phone:860-444-8402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient