Provider Demographics
NPI:1144423617
Name:AHC LYSTER-FT NOVOSEL
Entity type:Organization
Organization Name:AHC LYSTER-FT NOVOSEL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:UBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PERDUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-255-7244
Mailing Address - Street 1:301 ANDREWS ROAD
Mailing Address - Street 2:ATTN MCXY-RM-TPCP
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5000
Mailing Address - Country:US
Mailing Address - Phone:334-255-7244
Mailing Address - Fax:
Practice Address - Street 1:4405 INNKEEPER STREET
Practice Address - Street 2:
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AHC LYSTER-FT NOVOSEL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-11
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient