Provider Demographics
NPI:1073675955
Name:375TH MEDICAL GROUP
Entity Type:Organization
Organization Name:375TH MEDICAL GROUP
Other - Org Name:SCOTT HOSP 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 1:310 W LOSEY ST
Mailing Address - Street 2:BLDG 1530
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225-5250
Mailing Address - Country:US
Mailing Address - Phone:618-256-7345
Mailing Address - Fax:618-256-7131
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:BLDG 1530
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-7345
Practice Address - Fax:618-256-7131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2024967OtherPK