Basic Information
| Provider Information | |||||||||
| NPI: | 1619365285 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKE ARMY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | CBMH WESTOVER-JB SAN ANTONIO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | MCHE-COU-T DEPT 211 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109168558 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10010 ROGERS RUN | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782514403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109164141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2015 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | BALLARD | ||||||||
| AuthorizedOfficialFirstName: | CLENTON | ||||||||
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| AuthorizedOfficialTitleorPosition: | UBO MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2109168561 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BROOKE ARMY MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
ID Information
| ID | Type | State | Issuer | Description | 1538251764 | 01 | PARENT FACILITY NPI 2 | OTHER |