1487069621 NPI number — 21ST MEDICAL GROUP

Table of content: (NPI 1487069621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487069621 NPI number — 21ST MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
21ST MEDICAL GROUP
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:
DOD SCHRIEVER EPHCY
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:
1487069621
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21ST MEDICAL GROUP C/O RMO OFFICE
Provider Second Line Business Mailing Address:
559 VINCENT ST
Provider Business Mailing Address City Name:
PETERSON AFB
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80914-1541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-567-4423
Provider Business Mailing Address Fax Number:
719-567-4817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 FALCON PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHRIEVER AFB
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80912-5005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-567-4423
Provider Business Practice Location Address Fax Number:
719-567-4817
Provider Enumeration Date:
06/26/2014

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: 2146548 . This is a "PK" identifier . This identifiers is of the category "OTHER".