Provider Demographics
NPI:1053399188
Name:47TH MEDICAL GROUP
Entity type:Organization
Organization Name:47TH MEDICAL GROUP
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 1:590 MITCHELL BLVD
Mailing Address - Street 2:47 MDSS SGSRR
Mailing Address - City:LAUGHLIN AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78843-5242
Mailing Address - Country:US
Mailing Address - Phone:830-398-6320
Mailing Address - Fax:830-298-6439
Practice Address - Street 1:590 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:LAUGHLIN AFB
Practice Address - State:TX
Practice Address - Zip Code:78843-5242
Practice Address - Country:US
Practice Address - Phone:830-398-6320
Practice Address - Fax:830-298-6439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2014-03-03
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
TX4510536OtherPHARMACY NABP
TX4510536OtherNCPDP
TXVAD00000Medicare ID - Type UnspecifiedLAUGHLIN FACILITY