Provider Demographics
NPI:1285624262
Name:55 MDOS
Entity type:Organization
Organization Name:55 MDOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENAL HEALTH FLIGHT COMMANDER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:F
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:402-294-7883
Mailing Address - Street 1:55 MDOS SGO
Mailing Address - Street 2:2501 CAPEHART RD
Mailing Address - City:OFFUTT A F B
Mailing Address - State:NE
Mailing Address - Zip Code:68113-1712
Mailing Address - Country:US
Mailing Address - Phone:402-294-7883
Mailing Address - Fax:
Practice Address - Street 1:55 MDOS SGO
Practice Address - Street 2:2501 CAPEHART RD
Practice Address - City:OFFUTT A F B
Practice Address - State:NE
Practice Address - Zip Code:68113-1712
Practice Address - Country:US
Practice Address - Phone:402-294-7883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK679103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty