Provider Demographics
NPI:1881650141
Name:87 MEDICAL GROUP
Entity Type:Organization
Organization Name:87 MEDICAL GROUP
Other - Org Name:JB MCGUIRE-DIX-LAKEHURST MTF
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 1:3458 NEELY RD
Mailing Address - Street 2:MDSS SGSBR
Mailing Address - City:MC GUIRE AFB
Mailing Address - State:NJ
Mailing Address - Zip Code:08641-5312
Mailing Address - Country:US
Mailing Address - Phone:609-754-9658
Mailing Address - Fax:609-754-9541
Practice Address - Street 1:3458 NEELY RD
Practice Address - Street 2:MDSS SGSBR
Practice Address - City:MC GUIRE AFB
Practice Address - State:NJ
Practice Address - Zip Code:08641-5312
Practice Address - Country:US
Practice Address - Phone:609-754-9658
Practice Address - Fax:609-754-9541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2014-02-20
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
NJ31-41847OtherNCPDP