Provider Demographics
NPI:1063484707
Name:325 MEDICAL GROUP
Entity Type:Organization
Organization Name:325 MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AIR FORCE UNIFORM BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-681-7613
Mailing Address - Street 1:340 MAGNOLIA CIR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32403-5604
Mailing Address - Country:US
Mailing Address - Phone:850-283-7736
Mailing Address - Fax:850-283-7191
Practice Address - Street 1:340 MAGNOLIA CIR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32403-5604
Practice Address - Country:US
Practice Address - Phone:850-283-7736
Practice Address - Fax:850-283-7191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2014-07-29
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
FL1075286OtherNCPDP