Provider Demographics
NPI:1033445085
Name:22ND MEDICAL GROUP
Entity Type:Organization
Organization Name:22ND MEDICAL GROUP
Other - Org Name:MCCONNELL HD PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF DHA PASS
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-536-6650
Mailing Address - Street 1:57950 LEAVENWORTH ST
Mailing Address - Street 2:BUILDING 250
Mailing Address - City:MCCONNELL AFB
Mailing Address - State:KS
Mailing Address - Zip Code:67221-3506
Mailing Address - Country:US
Mailing Address - Phone:316-759-4203
Mailing Address - Fax:316-759-5014
Practice Address - Street 1:57950 LEAVENWORTH ST
Practice Address - Street 2:BUILDING 250
Practice Address - City:MCCONNELL AFB
Practice Address - State:KS
Practice Address - Zip Code:67221-3506
Practice Address - Country:US
Practice Address - Phone:316-759-4203
Practice Address - Fax:316-759-5014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122544OtherPK