Provider Demographics
NPI:1275568909
Name:WRIGHT-PATTERSON MEDICAL CENTER
Entity Type:Organization
Organization Name:WRIGHT-PATTERSON MEDICAL CENTER
Other - Org Name:88TH MEDICAL GROUP
Other - Org Type:Other Name
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 1:88 MDSS/SGSRT
Mailing Address - Street 2:4881 SUGAR MAPLE DRIVE
Mailing Address - City:WRIGHT PATTERSON
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5546
Mailing Address - Country:US
Mailing Address - Phone:937-257-0803
Mailing Address - Fax:937-656-2656
Practice Address - Street 1:88 MDSS/SGSRT
Practice Address - Street 2:4881 SUGAR MAPLE DRIVE
Practice Address - City:WRIGHT PATTERSON
Practice Address - State:OH
Practice Address - Zip Code:45433-5546
Practice Address - Country:US
Practice Address - Phone:937-257-0803
Practice Address - Fax:937-656-2656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1100X, 261QM1101X, 332000000X
OH2865M2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital
No261QM1100XAmbulatory 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
OH36-66851OtherNCPDP