Provider Demographics
NPI:1710967526
Name:KEESLER MEDICAL CENTER 81MDSS SGSR
Entity Type:Organization
Organization Name:KEESLER MEDICAL CENTER 81MDSS SGSR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AIR FORCE UNIFORM BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HANSKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-588-6419
Mailing Address - Street 1:301 FISHER ST
Mailing Address - Street 2:STE 101 RM 1A132
Mailing Address - City:KEESLER AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2508
Mailing Address - Country:US
Mailing Address - Phone:228-377-4526
Mailing Address - Fax:228-377-4559
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:STE 101 RM 1A132
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:228-377-4526
Practice Address - Fax:228-377-4559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital
No261QM1100XAmbulatory 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
MS2518338OtherNCPDP