Provider Demographics
NPI:1891756151
Name:6TH MEDICAL GROUP
Entity Type:Organization
Organization Name:6TH MEDICAL GROUP
Other - Org Name:MACDILL AFB MTF
Other - Org Type:Other Name
Authorized Official - Title/Position:AIR FORCE UBO ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RIDDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-681-6384
Mailing Address - Street 1:3250 ZEMKE AVE
Mailing Address - Street 2:
Mailing Address - City:MACDILL AFB
Mailing Address - State:FL
Mailing Address - Zip Code:33621
Mailing Address - Country:US
Mailing Address - Phone:813-827-9160
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE
Practice Address - Street 2:
Practice Address - City:MACDILL AFB
Practice Address - State:FL
Practice Address - Zip Code:33621
Practice Address - Country:US
Practice Address - Phone:813-827-9160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2016-04-21
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
FL10-81520OtherNCPDP