Provider Demographics
NPI:1386652956
Name:AHC MONCRIEF-JACKSON
Entity type:Organization
Organization Name:AHC MONCRIEF-JACKSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:UBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIYE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-751-0472
Mailing Address - Street 1:4500 STUART ST
Mailing Address - Street 2:BOX 497
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5720
Mailing Address - Country:US
Mailing Address - Phone:803-751-0472
Mailing Address - Fax:803-751-0415
Practice Address - Street 1:4500 STUART ST
Practice Address - Street 2:
Practice Address - City:FORT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207-5720
Practice Address - Country:US
Practice Address - Phone:803-751-2160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AHC MONCRIEF-JACKSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-03
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QM1100X, 261QM1101X, 2865M2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
Provider Identifiers
StateIdentifier IDID TypeIssuer
42-22802OtherNCPDP
AN2598588OtherMEDCO ID
42-22802OtherNCPDP
AN2598588OtherMEDCO ID