Provider Demographics
NPI:1912982810
Name:377TH MEDGRP-KIRTLAND
Entity type:Organization
Organization Name:377TH MEDGRP-KIRTLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DHA UBO
Authorized Official - Prefix:
Authorized Official - First Name:JEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWANDOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-817-4030
Mailing Address - Street 1:2050A SECOND ST SE
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND AFB
Mailing Address - State:NM
Mailing Address - Zip Code:87117-5524
Mailing Address - Country:US
Mailing Address - Phone:505-846-3605
Mailing Address - Fax:505-846-3594
Practice Address - Street 1:2050A SECOND ST SE
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-5524
Practice Address - Country:US
Practice Address - Phone:505-846-3605
Practice Address - Fax:505-846-3594
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:377TH MEDGRP-KIRTLAND
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-13
Last Update Date:2025-06-17
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
NM32-08926OtherNCPDP
NM32-08926OtherNCPDP