Provider Demographics
NPI:1306095104
Name:31 MEDICAL GROUP
Entity type:Organization
Organization Name:31 MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENELOPE
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:GORSUCH
Authorized Official - Suffix:
Authorized Official - Credentials:ACNP
Authorized Official - Phone:043-430-5038
Mailing Address - Street 1:PSC 103 BOX 3186
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09603-0032
Mailing Address - Country:US
Mailing Address - Phone:043-430-5038
Mailing Address - Fax:
Practice Address - Street 1:PSC 103 BOX 3186
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09603-0032
Practice Address - Country:US
Practice Address - Phone:043-430-5038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA089304286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital