Healthcare Provider Details

I. General information

NPI: 1093782880
Provider Name (Legal Business Name): 97TH MEDGRP-ALTUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 1ST ST BLDG 46
ALTUS AFB OK
73523-5004
US

IV. Provider business mailing address

301 N 1ST ST BLDG 46
ALTUS AFB OK
73523-5004
US

V. Phone/Fax

Practice location:
  • Phone: 580-481-5400
  • Fax: 580-481-5416
Mailing address:
  • Phone: 580-481-5400
  • Fax: 580-481-5416

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: DHA UBO
Credential:
Phone: 703-817-4030