Healthcare Provider Details

I. General information

NPI: 1336112440
Provider Name (Legal Business Name): 20TH MEDGRP-SHAW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 MEADOWLARK ST
SHAW AFB SC
29152-5019
US

IV. Provider business mailing address

431 MEADOWLARK ST
SHAW AFB SC
29152-5019
US

V. Phone/Fax

Practice location:
  • Phone: 803-895-6526
  • Fax: 803-895-6419
Mailing address:
  • Phone: 803-895-6526
  • Fax: 803-895-6419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State
# 3
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