Organization
EISENHOWER ARMY MEDICAL CENTER
Active
Parent organization
EISENHOWER ARMY MEDICAL CENTER
Other names
SOUTHCOM CLINIC-FT. GORDON
Organization subpart
Yes
Provider details
NPI number
Legal business name
EISENHOWER ARMY MEDICAL CENTER
Authorized official
MARVIN PRIMOS (UBO MANAGER)
(706) 787-7204
Entity
Organization
Contact information
Practice address
3511 NW 91ST AVE, DORAL, FL 33172-1216
(305) 437-1970
Mailing address
300 W HOSPITAL RD BLDG W, ATTN MCHF-PAD, FORT GORDON, GA 30905-5741
(706) 787-1125
Taxonomy
Speciality
Code
Description
License number
State
261QM1100X
Military/U.S. Coast Guard Outpatient Clinic/Center
Primary
—
—
332000000X
Military/U.S. Coast Guard Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1578660742
PARENT MTF NPI
—
Enumeration date
05/09/2007
Last updated
01/05/2015
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