1588647770 NPI number — 96TH MEDICAL GROUP

Table of content: (NPI 1588647770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588647770 NPI number — 96TH MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
96TH 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:
96TH MEDICAL SUPPORT SQUADRON OR 96 MDSS SGSR
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:
1588647770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
307 BOATNER RD
Provider Second Line Business Mailing Address:
SUITE 114
Provider Business Mailing Address City Name:
EGLIN AFB
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32542-1302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-883-9015
Provider Business Mailing Address Fax Number:
850-883-8659

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 BOATNER RD
Provider Second Line Business Practice Location Address:
SUITE 114
Provider Business Practice Location Address City Name:
EGLIN AFB
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32542-1302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-883-9015
Provider Business Practice Location Address Fax Number:
850-883-8659
Provider Enumeration Date:
11/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
AIR FORCE UNIFORM BUSINESS OFFICE
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: "N" .
  • Taxonomy code: 2865M2000X ; 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: 10-79260 . This is a "NCPDP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com