Healthcare Provider Details

I. General information

NPI: 1033196878
Provider Name (Legal Business Name): 42D MEDGRP-MAXWELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SOUTH TWINING ST BUILDING 760
MAXWELL AFB AL
36112-6219
US

IV. Provider business mailing address

300 SOUTH TWINING ST BUILDING 760
MAXWELL AFB AL
36112-6219
US

V. Phone/Fax

Practice location:
  • Phone: 334-953-4943
  • Fax: 334-953-1741
Mailing address:
  • Phone: 334-953-4943
  • Fax: 334-953-1741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEN LEWANDOWSKI
Title or Position: DEFENSE HEALTH AGENCY (DHA) FINANCI
Credential:
Phone: 703-817-4030