Provider Demographics
NPI:1902787500
Name:MIKE O'CALLAGHAN MILITARY MEDICAL CENTER
Entity type:Organization
Organization Name:MIKE O'CALLAGHAN MILITARY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IDMT
Authorized Official - Prefix:
Authorized Official - First Name:ROSS K
Authorized Official - Middle Name:
Authorized Official - Last Name:KONICKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-653-2273
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6600
Mailing Address - Country:US
Mailing Address - Phone:702-653-2273
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6600
Practice Address - Country:US
Practice Address - Phone:702-653-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical TechniciansGroup - Single Specialty