Healthcare Provider Details

I. General information

NPI: 1952582009
Provider Name (Legal Business Name): HICKAM AFB 15TH MDG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 SCOTT CIR 15TH MED GROUP
HICKAM AFB HI
96853-5399
US

IV. Provider business mailing address

755 SCOTT CIR 15TH MED GROUP
HICKAM AFB HI
96853-5399
US

V. Phone/Fax

Practice location:
  • Phone: 808-448-6133
  • Fax:
Mailing address:
  • Phone: 808-448-6133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number14816
License Number StateHI

VIII. Authorized Official

Name: MERCEDES HAMILTON
Title or Position: REFERRAL MANAGER
Credential: LPN
Phone: 808-448-6133