Provider Demographics
NPI:1336112440
Name:20TH MEDICAL GROUP SHAW
Entity Type:Organization
Organization Name:20TH MEDICAL GROUP SHAW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AF UBO ANALYST
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-681-7613
Mailing Address - Street 1:431 MEADOWLARK ST
Mailing Address - Street 2:
Mailing Address - City:SHAW AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29152-5019
Mailing Address - Country:US
Mailing Address - Phone:803-895-6526
Mailing Address - Fax:803-895-6419
Practice Address - Street 1:431 MEADOWLARK ST
Practice Address - Street 2:
Practice Address - City:SHAW AFB
Practice Address - State:SC
Practice Address - Zip Code:29152-5019
Practice Address - Country:US
Practice Address - Phone:803-895-6526
Practice Address - Fax:803-895-6419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2014-03-28
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
SC4222903OtherNCPDP