Provider Demographics
NPI:1609859891
Name:633RD MEDICAL GROUP - LANGLEY AFB
Entity Type:Organization
Organization Name:633RD MEDICAL GROUP - LANGLEY AFB
Other - Org Name:1ST MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DHA FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:77 NEALY AVE
Mailing Address - Street 2:
Mailing Address - City:LANGLEY AFB
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2040
Mailing Address - Country:US
Mailing Address - Phone:757-764-6807
Mailing Address - Fax:757-764-0821
Practice Address - Street 1:77 NEALY AVE
Practice Address - Street 2:
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:757-764-6807
Practice Address - Fax:757-764-0821
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:633D MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-22
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital
Yes261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000686OtherBCBS
VA4834722OtherNCPDP