Provider Demographics
NPI:1275511776
Name:WILFORD HALL MEDICAL CENTER
Entity Type:Organization
Organization Name:WILFORD HALL MEDICAL CENTER
Other - Org Name:59 MDW ADBS
Other - Org Type:Other Name
Authorized Official - Title/Position:AIR FORCE UBO ANALYST
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 1:2200 BERGQUIST DR
Mailing Address - Street 2:SUITE 1 ADBS
Mailing Address - City:LACKLAND A F B
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9907
Mailing Address - Country:US
Mailing Address - Phone:210-292-7575
Mailing Address - Fax:210-292-2592
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:SUITE 1 ADBS
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-292-7575
Practice Address - Fax:210-292-2592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1100X, 261QM1101X, 332000000X
TX2865M000X2865M2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
Yes261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX021757201Medicaid
TX4596776OtherNCPDP
TXHH6032OtherBLUE CROSS BLUE SHIELD
TX4596776OtherNCPDP