Healthcare Provider Details

I. General information

NPI: 1427031673
Provider Name (Legal Business Name): 5TH MEDGRP-MINOT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MISSILE AVE
MINOT AFB ND
58705-5003
US

IV. Provider business mailing address

10 MISSILE AVE
MINOT AFB ND
58705-5003
US

V. Phone/Fax

Practice location:
  • Phone: 701-723-5995
  • Fax: 630-570-6075
Mailing address:
  • Phone: 701-723-5995
  • Fax: 630-570-6074

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: JEN LEWANDOWSKI
Title or Position: DHA UBO
Credential:
Phone: 703-817-4030