Provider Demographics
NPI:1912971441
Name:75TH MEDICAL GROUP SGSB
Entity Type:Organization
Organization Name:75TH MEDICAL GROUP SGSB
Other - Org Name:HILL AFB MTF
Other - Org Type:Other Name
Authorized Official - Title/Position:AIR FORCE UNIFORM BUSINESS OFFICE
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:703-588-6419
Mailing Address - Street 1:7321 11TH ST
Mailing Address - Street 2:BLDG 570
Mailing Address - City:HILL AFB
Mailing Address - State:UT
Mailing Address - Zip Code:84056-5012
Mailing Address - Country:US
Mailing Address - Phone:801-586-9548
Mailing Address - Fax:801-777-6919
Practice Address - Street 1:7321 11TH ST
Practice Address - Street 2:BLDG 570
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-586-9548
Practice Address - Fax:801-777-6919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1100X, 261QM1101X, 332000000X
UT286500000X
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
No286500000XHospitalsMilitary Hospital
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT46-09256OtherNCPDP
UT1134228257OtherNPPES