Provider Demographics
NPI:1972643401
Name:79TH MEDICAL GROUP MALCOLM GROW MEDICAL CENTER
Entity type:Organization
Organization Name:79TH MEDICAL GROUP MALCOLM GROW MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADULT NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:GISCOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:240-857-4951
Mailing Address - Street 1:11423 PLENTY GATES CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-5601
Mailing Address - Country:US
Mailing Address - Phone:301-645-3357
Mailing Address - Fax:240-857-7138
Practice Address - Street 1:1050 W PERIMETER RD
Practice Address - Street 2:MALCOLM GROW MEDICAL CENTER
Practice Address - City:ANDREWS AIR FORCE BASE
Practice Address - State:MD
Practice Address - Zip Code:20762-6601
Practice Address - Country:US
Practice Address - Phone:240-857-4951
Practice Address - Fax:240-857-7138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN64518286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital