Healthcare Provider Details

I. General information

NPI: 1679540900
Provider Name (Legal Business Name): 36TH MEDGRP-MARIANAS GUAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2006
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 14010
APO AP
96543 4010
UM

IV. Provider business mailing address

UNIT 14010
APO AP
96543 4010
UM

V. Phone/Fax

Practice location:
  • Phone: 671-366-6315
  • Fax:
Mailing address:
  • Phone: 671-366-6315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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