1285618363 NPI number — 72ND MEDICAL GROUP - TINKER AFB

Table of content: (NPI 1285618363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285618363 NPI number — 72ND MEDICAL GROUP - TINKER AFB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
72ND MEDICAL GROUP - TINKER AFB
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:
72D MEDICAL GROUP
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:
1285618363
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7050 AIR DEPOT TINKER AFB
Provider Second Line Business Mailing Address:
BUILDING 1094
Provider Business Mailing Address City Name:
TINKER AFB
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-582-6035
Provider Business Mailing Address Fax Number:
405-736-3892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7050 AIR DEPOT TINKER AFB
Provider Second Line Business Practice Location Address:
BUILDING 1094
Provider Business Practice Location Address City Name:
TINKER AFB
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-582-6033
Provider Business Practice Location Address Fax Number:
405-736-3892
Provider Enumeration Date:
12/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CONDON
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
DHA FINANCIAL MANAGER
Authorized Official Telephone Number:
240-401-3643

Provider Taxonomy Codes

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

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





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