1780781534 NPI number — 56TH MEDICAL GROUP SGSL

Table of content: (NPI 1780781534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780781534 NPI number — 56TH MEDICAL GROUP SGSL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
56TH 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:
LUKE HOSP 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:
1780781534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7219 N LITCHFIELD RD
Provider Second Line Business Mailing Address:
BLDG 1130 56 MDSS/SGSR
Provider Business Mailing Address City Name:
LUKE AFB
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85309-1529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-856-3068
Provider Business Mailing Address Fax Number:
623-856-6120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7219 N LITCHFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUKE AFB
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85309-1529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-856-3068
Provider Business Practice Location Address Fax Number:
623-856-6120
Provider Enumeration Date:
09/20/2006

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: 1990495 . This is a "PK" identifier . This identifiers is of the category "OTHER".