Provider Demographics
NPI:1093782880
Name:97TH MEDICAL GROUP
Entity Type:Organization
Organization Name:97TH MEDICAL GROUP
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 1:301 N 1ST ST
Mailing Address - Street 2:BLDG 46
Mailing Address - City:ALTUS AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73523-5004
Mailing Address - Country:US
Mailing Address - Phone:580-481-5400
Mailing Address - Fax:580-481-5416
Practice Address - Street 1:301 N 1ST ST
Practice Address - Street 2:BLDG 46
Practice Address - City:ALTUS AFB
Practice Address - State:OK
Practice Address - Zip Code:73523-5004
Practice Address - Country:US
Practice Address - Phone:580-481-5400
Practice Address - Fax:580-481-5416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2010-11-15
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
OK3720225OtherNCPDP
OK3720225OtherNCPDP