Provider Demographics
NPI:1104805142
Name:17TH MEDICAL GROUP
Entity type:Organization
Organization Name:17TH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AIR FORCE UNIFORM BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HANSKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-588-6419
Mailing Address - Street 1:271 FORT RICHARDSON AVE
Mailing Address - Street 2:
Mailing Address - City:GOODFELLOW AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76908-4901
Mailing Address - Country:US
Mailing Address - Phone:325-654-5974
Mailing Address - Fax:325-654-3121
Practice Address - Street 1:271 FORT RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:GOODFELLOW AFB
Practice Address - State:TX
Practice Address - Zip Code:76908-4901
Practice Address - Country:US
Practice Address - Phone:325-654-5974
Practice Address - Fax:325-654-3121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1101X, 332000000X
TX261QM1100X
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
TX4596740OtherNCPDP
TXVADOOOMedicare UPIN