Basic Information
| Provider Information | |||||||||
| NPI: | 1922195510 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKE ARMY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMC BAMC-FSH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | MCHE-COU-M DEPT 211 | ||||||||
| City: | FT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109168563 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3851 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | JBSA FT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109164141 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALPIZAR | ||||||||
| AuthorizedOfficialFirstName: | NORA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF, UNIFORM BUSINESS OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 2109168563 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient | 261QM1101X | N | Ambulatory Health Care Facilities | Clinic/Center | Military and U.S. Coast Guard Ambulatory Procedure | 286500000X | N | Hospitals | Military Hospital | 2865M2000X | N | Hospitals | Military Hospital | Military General Acute Care Hospital | 286500000X | TX | Y | Hospitals | Military Hospital |
ID Information
| ID | Type | State | Issuer | Description | 021756401 | 05 | TX | MEDICAID | 36JK | 01 | TX | BC BS PROVIDER NUMBER | OTHER | HH6037 | 01 | TX | BC BS PROVIDER NUMBER | OTHER | 4503884 | 01 | NCPDP | OTHER | AN2598588 | 01 | MEDCO | OTHER |