Provider Demographics
NPI:1588638167
Name:US AIR FORCE 15 CPTS FMF PC
Entity Type:Organization
Organization Name:US AIR FORCE 15 CPTS FMF PC
Other - Org Name:15TH MEDICAL GROUP
Other - Org Type:Doing Business As
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 1:15TH MEDICAL GROUP SGSBR
Mailing Address - Street 2:755 SCOTT CIRCLE
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96853-5399
Mailing Address - Country:US
Mailing Address - Phone:808-449-2295
Mailing Address - Fax:808-449-2297
Practice Address - Street 1:15TH MEDICAL GROUP SGSBR
Practice Address - Street 2:755 SCOTT CIRCLE
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96853-5399
Practice Address - Country:US
Practice Address - Phone:808-449-2295
Practice Address - Fax:808-449-2297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2014-03-07
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
HI12-03900OtherNCPDP
HI1649379322OtherNPPES