Provider Demographics
NPI:1902259948
Name:EVANS ARMY COMMUNITY HOSPITAL PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:EVANS ARMY COMMUNITY HOSPITAL PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF, PEDIATRIC CLINIC
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-526-7653
Mailing Address - Street 1:1650 COCHRANE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4613
Mailing Address - Country:US
Mailing Address - Phone:719-526-7653
Mailing Address - Fax:719-526-7673
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-526-7653
Practice Address - Fax:719-526-7673
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVANS ARMY COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care