1063511707 NPI number — 45TH MEDICAL GROUP SGSL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063511707 NPI number — 45TH MEDICAL GROUP SGSL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
45TH MEDICAL GROUP SGSL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PATRICK SATL PHCY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063511707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1381 S PATRICK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PATRICK AFB
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32925-3606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-494-8991
Provider Business Mailing Address Fax Number:
321-494-7996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1381 S PATRICK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PATRICK AFB
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32925-3606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-494-8991
Provider Business Practice Location Address Fax Number:
321-494-7996
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORALES
Authorized Official First Name:
HECTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF DHA PASS
Authorized Official Telephone Number:
210-536-6650

Provider Taxonomy Codes

  • Taxonomy code: 332000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2013107 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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