Provider Demographics
NPI:1033196480
Name:509TH MEDICAL GROUP-SGSR
Entity Type:Organization
Organization Name:509TH MEDICAL GROUP-SGSR
Other - Org Name:WHITEMAN AFB MTF
Other - Org Type:Other Name
Authorized Official - Title/Position:AIR FORCE UBO ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-681-7613
Mailing Address - Street 1:331 SIJAN AVE
Mailing Address - Street 2:509 MDSS SGSR
Mailing Address - City:WHITEMAN AFB
Mailing Address - State:MO
Mailing Address - Zip Code:65305-1269
Mailing Address - Country:US
Mailing Address - Phone:660-687-1838
Mailing Address - Fax:660-687-5121
Practice Address - Street 1:331 SIJAN AVE
Practice Address - Street 2:509 MDSS SGSR
Practice Address - City:WHITEMAN AFB
Practice Address - State:MO
Practice Address - Zip Code:65305-1269
Practice Address - Country:US
Practice Address - Phone:660-687-1838
Practice Address - Fax:660-687-5121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2632897OtherNCPDP