Provider Demographics
NPI:1043270549
Name:62D MEDICAL GROUP USAF
Entity Type:Organization
Organization Name:62D MEDICAL GROUP USAF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AIR FORCE UNIFORM BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HANSKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-588-6419
Mailing Address - Street 1:690 A ST
Mailing Address - Street 2:
Mailing Address - City:MCCHORD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:98438-1303
Mailing Address - Country:US
Mailing Address - Phone:253-982-5586
Mailing Address - Fax:253-982-5978
Practice Address - Street 1:690 A ST
Practice Address - Street 2:
Practice Address - City:MCCHORD AFB
Practice Address - State:WA
Practice Address - Zip Code:98438-1303
Practice Address - Country:US
Practice Address - Phone:253-982-5586
Practice Address - Fax:253-982-5978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2010-11-12
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
WA49-27197OtherNCPDP
VAD000Medicare UPIN