Provider Demographics
NPI:1891765046
Name:95TH MEDICAL GROUP SGSR
Entity Type:Organization
Organization Name:95TH MEDICAL GROUP SGSR
Other - Org Name:
Other - Org Type:
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 1:30 NIGHTINGALE RD
Mailing Address - Street 2:BLDG 5525
Mailing Address - City:EDWARDS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:93524-0001
Mailing Address - Country:US
Mailing Address - Phone:661-275-2634
Mailing Address - Fax:661-277-6645
Practice Address - Street 1:30 NIGHTINGALE RD
Practice Address - Street 2:BLDG 5525
Practice Address - City:EDWARDS AFB
Practice Address - State:CA
Practice Address - Zip Code:93524-0001
Practice Address - Country:US
Practice Address - Phone:661-275-2634
Practice Address - Fax:661-277-6645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2014-03-10
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
CA05-40345OtherNCPDP