Provider Demographics
NPI:1043632771
Name:UNITED STATES NAVY
Entity type:Organization
Organization Name:UNITED STATES NAVY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PA
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MPAS
Authorized Official - Phone:760-725-3213
Mailing Address - Street 1:2005 KNIGHT LANE BLDG H
Mailing Address - Street 2:NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-0140
Mailing Address - Country:US
Mailing Address - Phone:760-725-3213
Mailing Address - Fax:
Practice Address - Street 1:2005 KNIGHT LANE BLDG H
Practice Address - Street 2:NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:760-725-3213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1103XAmbulatory Health Care FacilitiesClinic/CenterMilitary Ambulatory Procedure Visits Operational (Transportable)