Provider Demographics
NPI:1114905775
Name:628 MEDICAL GROUP
Entity Type:Organization
Organization Name:628 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 1:204 W HILL BLVD
Mailing Address - Street 2:BLDG 364
Mailing Address - City:CHARLESTON AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29404-4704
Mailing Address - Country:US
Mailing Address - Phone:843-963-6884
Mailing Address - Fax:843-963-6538
Practice Address - Street 1:204 W HILL BLVD
Practice Address - Street 2:BLDG 364
Practice Address - City:CHARLESTON AFB
Practice Address - State:SC
Practice Address - Zip Code:29404-4704
Practice Address - Country:US
Practice Address - Phone:843-963-6884
Practice Address - Fax:843-963-6538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2012-01-27
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
SC42-22181OtherNCPDP