Provider Demographics
NPI:1508831553
Name:66 MDSS-SGSR
Entity Type:Organization
Organization Name:66 MDSS-SGSR
Other - Org Name:HANSCOM MTF
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:MARIE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-681-7613
Mailing Address - Street 1:90 VANDENBERG DR
Mailing Address - Street 2:BLDG 1900
Mailing Address - City:HANSCOM AFB
Mailing Address - State:MA
Mailing Address - Zip Code:01731-2104
Mailing Address - Country:US
Mailing Address - Phone:781-377-1770
Mailing Address - Fax:781-377-9840
Practice Address - Street 1:90 VANDENBERG DR
Practice Address - Street 2:BLDG 1900
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731-2104
Practice Address - Country:US
Practice Address - Phone:781-377-1770
Practice Address - Fax:781-377-9840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2014-02-18
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
MA22-38029OtherNCPDP
MA1124016878Medicare UPIN
MA1225011844Medicare UPIN
MA22-38029OtherNCPDP
MA1053305391Medicare UPIN
MA1528058781Medicare UPIN
MA1306830484Medicare UPIN