MEDICARE: 92D MEDGRP-FAIRCHILD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM1101X	Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center
2	332000000X	Military/U.S. Coast Guard Pharmacy
3	261QM1100X	Military/U.S. Coast Guard Outpatient Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	49-24507	OTHER	WA	NCPDP

General Provider Information

NPI Number	:	1104888288
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	92D MEDGRP-FAIRCHILD

Provider Business Mailing Address
First Line	:	701 HOSPITAL LOOP
Second Line	:
City	:	FAIRCHILD AFB
State	:	WA
Zip	:	99011-8704
Country	:	US
Telephone Number	:	509-247-9264
Fax Number	:	509-247-3535

Provider Business Practice Location Address
First Line	:	701 HOSPITAL LOOP
Second Line	:
City	:	FAIRCHILD AFB
State	:	WA
Zip	:	99011-8704
Country	:	US
Telephone Number	:	509-247-9264
Fax Number	:	509-247-3535

Authorized Official
Title or Position	:	DHA UBO
Name	:	JEN LEWANDOWSKI
Credential	:
Telephone Number	:	703-817-4030

Provider Enumeration Date	:	04/04/2006
Last Update Date	:	06/17/2025

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Directions to “92D MEDGRP-FAIRCHILD ” Practice Location

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