Healthcare Provider Details

I. General information

NPI: 1619957586
Provider Name (Legal Business Name): 43RD MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

383 MAYNARD ST 43RD MEDICAL GROUP
POPE AFB NC
28308-2321
US

IV. Provider business mailing address

383 MAYNARD ST 43RD MEDICAL GROUP
POPE AFB NC
28308-2321
US

V. Phone/Fax

Practice location:
  • Phone: 910-394-2205
  • Fax: 910-394-2077
Mailing address:
  • Phone: 910-394-2205
  • Fax: 910-394-2077

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

VIII. Authorized Official

Name: SERENA LYNN HANSKEN
Title or Position: AIR FORCE UNIFORM BUSINESS OFFICE P
Credential:
Phone: 703-588-6419