Provider Demographics
NPI:1972823722
Name:MONCRIEF ARMY COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:MONCRIEF ARMY COMMUNITY HOSPITAL
Other - Org Name:CBMH MONCRIEF-JACKSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF, UBO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-751-0472
Mailing Address - Street 1:4500 STUART ST
Mailing Address - Street 2:BOX 497 - BILLING OFFICE
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5700
Mailing Address - Country:US
Mailing Address - Phone:803-751-0472
Mailing Address - Fax:
Practice Address - Street 1:1021 PINNANCLE POINT
Practice Address - Street 2:MONCRIEF MEDICAL HOME-JACKSON
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-5740
Practice Address - Country:US
Practice Address - Phone:803-751-6971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONCRIEF ARMY COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-03
Last Update Date:2015-04-08
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
1386652956OtherPARENT FACILITY NPI 2
VAD000Medicare UPIN
OTH000Medicare UPIN