Provider Demographics
NPI:1952492316
Name:USCG MEDICAL CLINIC ELIZABETH CITY
Entity Type:Organization
Organization Name:USCG MEDICAL CLINIC ELIZABETH CITY
Other - Org Name:STEPHEN C. PUSH MEMORIAL CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:TECHNICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:LEFEBRE
Authorized Official - Suffix:JR
Authorized Official - Credentials:TECHNICIAN
Authorized Official - Phone:252-335-6461
Mailing Address - Street 1:COMDT CG-1122 U S
Mailing Address - Street 2:2100 2ND ST SW, SUITE 5314
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20593-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:COMDT CG-1122 U S
Practice Address - Street 2:2100 2ND ST SW, SUITE 5314
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20593-0001
Practice Address - Country:US
Practice Address - Phone:252-335-6461
Practice Address - Fax:252-335-6255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Multi-Specialty