Provider Demographics
NPI:1023302957
Name:81ST MEDICAL GROUP
Entity type:Organization
Organization Name:81ST MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISSTANT
Authorized Official - Prefix:
Authorized Official - First Name:LARAMIE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:RICHMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-376-0440
Mailing Address - Street 1:301 FISHER ST
Mailing Address - Street 2:81 MDOS SGOF
Mailing Address - City:KEESLER AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2508
Mailing Address - Country:US
Mailing Address - Phone:228-376-0440
Mailing Address - Fax:
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:81 MDOS SGOF
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:228-376-0440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital