Provider Demographics
NPI:1902982325
Name:MARTIN ARMY COMMUNITY HOSPTIAL
Entity Type:Organization
Organization Name:MARTIN ARMY COMMUNITY HOSPTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OUTPATIENT REGISTERED DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:CHRISTIN
Authorized Official - Last Name:WICKER
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:706-544-3856
Mailing Address - Street 1:7950 MARTIN LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-5647
Mailing Address - Country:US
Mailing Address - Phone:706-544-3856
Mailing Address - Fax:706-544-1377
Practice Address - Street 1:496 MILL POND DRIVE
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867
Practice Address - Country:US
Practice Address - Phone:334-289-9578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002620286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD000Medicare UPIN