Provider Demographics
NPI:1285618363
Name:72D MEDGRP-TINKER
Entity type:Organization
Organization Name:72D MEDGRP-TINKER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DHA FINANCIAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:7050 AIR DEPOT TINKER AFB
Mailing Address - Street 2:BUILDING 1094
Mailing Address - City:TINKER AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73145
Mailing Address - Country:US
Mailing Address - Phone:405-582-6035
Mailing Address - Fax:405-736-3892
Practice Address - Street 1:7050 AIR DEPOT TINKER AFB
Practice Address - Street 2:BUILDING 1094
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145
Practice Address - Country:US
Practice Address - Phone:405-582-6033
Practice Address - Fax:405-736-3892
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:72D MEDGRP-TINKER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-02
Last Update Date:2025-03-12
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
VAD000Medicare UPIN