Provider Demographics
NPI:1609859826
Name:90TH MEDICAL GROUP-UNITED STATES AIR FORCE
Entity Type:Organization
Organization Name:90TH MEDICAL GROUP-UNITED STATES AIR FORCE
Other - Org Name:FE WARREN AFB
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 1:6900 ALDEN DR
Mailing Address - Street 2:
Mailing Address - City:FE WARREN AFB
Mailing Address - State:WY
Mailing Address - Zip Code:82005-3906
Mailing Address - Country:US
Mailing Address - Phone:307-773-5674
Mailing Address - Fax:307-773-6574
Practice Address - Street 1:6900 ALDEN DR BLDG 160
Practice Address - Street 2:
Practice Address - City:FE WARREN AFB
Practice Address - State:WY
Practice Address - Zip Code:82005-2945
Practice Address - Country:US
Practice Address - Phone:307-773-4855
Practice Address - Fax:307-773-3731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2023-02-27
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
WY52-03625OtherNCPDP