1275511776 NPI number — WILFORD HALL MEDICAL CENTER

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 1275511776 NPI number — WILFORD HALL MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILFORD HALL MEDICAL CENTER
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:
59 MDW ADBS
Provider Other Organization Name Type Code:
5
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:
1275511776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 BERGQUIST DR
Provider Second Line Business Mailing Address:
SUITE 1 ADBS
Provider Business Mailing Address City Name:
LACKLAND A F B
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78236-9907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-292-7575
Provider Business Mailing Address Fax Number:
210-292-2592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 BERGQUIST DR
Provider Second Line Business Practice Location Address:
SUITE 1 ADBS
Provider Business Practice Location Address City Name:
LACKLAND A F B
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78236-9907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-292-7575
Provider Business Practice Location Address Fax Number:
210-292-2592
Provider Enumeration Date:
01/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
AIR FORCE UBO ANALYST
Authorized Official Telephone Number:
703-681-7613

Provider Taxonomy Codes

  • Taxonomy code: 261QM1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 021757201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4596776 . This is a "NCPDP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: HH6032 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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