Provider Demographics
NPI:1366997108
Name:EISENHOWER ARMY MEDICAL CENTER
Entity type:Organization
Organization Name:EISENHOWER ARMY MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF DHA PASS
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-536-6650
Mailing Address - Street 1:EISENHOWER ARMY MEDICAL CENTER
Mailing Address - Street 2:300 W HOSPITAL RD ATTN: MCHF-PAD
Mailing Address - City:FT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9301 NW 33RD ST
Practice Address - Street 2:ARMY HEALTH CLINIC SOUTHCOM
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-1202
Practice Address - Country:US
Practice Address - Phone:305-437-1749
Practice Address - Fax:305-437-1149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2163700OtherPK