Provider Demographics
NPI:1760764393
Name:5TH MEDICAL GROUP
Entity Type:Organization
Organization Name:5TH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT DUTY MEDICAL TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-723-5190
Mailing Address - Street 1:10 MISSILE AVE
Mailing Address - Street 2:
Mailing Address - City:MINOT AFB
Mailing Address - State:ND
Mailing Address - Zip Code:58705-5003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 MISSILE AVE
Practice Address - Street 2:
Practice Address - City:MINOT AFB
Practice Address - State:ND
Practice Address - Zip Code:58705-5003
Practice Address - Country:US
Practice Address - Phone:701-723-5190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDB10355302865M2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital