Provider Demographics
NPI:1891857363
Name:99TH MEDICAL GROUP - MIKE O'CALLAGHAN FEDERAL HOSPITAL
Entity Type:Organization
Organization Name:99TH MEDICAL GROUP - MIKE O'CALLAGHAN FEDERAL HOSPITAL
Other - Org Name:NELLIS MOD PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF DHA PASS
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-536-6650
Mailing Address - Street 1:99 MDSS/SGSR 4700 N LAS VEGAS BLVD NORTH
Mailing Address - Street 2:ATTN: THIRD PARTY BILLING
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89191
Mailing Address - Country:US
Mailing Address - Phone:702-653-3589
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:BLDG 1300
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89191-6600
Practice Address - Country:US
Practice Address - Phone:702-653-3205
Practice Address - Fax:702-653-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2051373OtherPK