Provider Demographics
NPI:1831173558
Name:4TH MEDGRP-SEYMOUR JOHNSON
Entity type:Organization
Organization Name:4TH MEDGRP-SEYMOUR JOHNSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NCOIC, UNIFORM BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHTHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-722-8257
Mailing Address - Street 1:2803 MEDICAL CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR JOHNSON AFB
Mailing Address - State:NC
Mailing Address - Zip Code:27531
Mailing Address - Country:US
Mailing Address - Phone:919-722-8257
Mailing Address - Fax:
Practice Address - Street 1:2803 MEDICAL CAMPUS DRIVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR JOHNSON AFB
Practice Address - State:NC
Practice Address - Zip Code:27531-2310
Practice Address - Country:US
Practice Address - Phone:919-722-8257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:4TH MEDGRP-SEYMOUR JOHNSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-06
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM1101X, 261QM1100X
332000000X
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
NC3429405OtherNCPDP