Provider Demographics
NPI:1063487791
Name:366 MEDICAL GROUP
Entity Type:Organization
Organization Name:366 MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMMANDER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-828-7600
Mailing Address - Street 1:90 HOPE DRIVE BLDG 6000
Mailing Address - Street 2:366 MEDICAL GROUP SGSR
Mailing Address - City:MOUNTAIN HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648-1062
Mailing Address - Country:US
Mailing Address - Phone:208-828-7470
Mailing Address - Fax:208-828-2753
Practice Address - Street 1:90 HOPE DRIVE BLDG 6000
Practice Address - Street 2:366 MEDICAL GROUP
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648-1062
Practice Address - Country:US
Practice Address - Phone:208-828-7470
Practice Address - Fax:208-828-2753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1306845OtherNCPDP
ID8072078Medicaid
VAD000Medicare UPIN