MEDICARE: 628TH MEDGRP-CHARLESTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM1101X	Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center
2	332000000X	Military/U.S. Coast Guard Pharmacy
3	261QM1100X	Military/U.S. Coast Guard Outpatient Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	42-22181	OTHER	SC	NCPDP

General Provider Information

NPI Number	:	1114905775
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	628TH MEDGRP-CHARLESTON

Provider Business Mailing Address
First Line	:	204 W HILL BLVD
Second Line	:	BLDG 364
City	:	CHARLESTON AFB
State	:	SC
Zip	:	29404-4704
Country	:	US
Telephone Number	:	843-963-6884
Fax Number	:	843-963-6538

Provider Business Practice Location Address
First Line	:	204 W HILL BLVD
Second Line	:	BLDG 364
City	:	CHARLESTON AFB
State	:	SC
Zip	:	29404-4704
Country	:	US
Telephone Number	:	843-963-6884
Fax Number	:	843-963-6538

Authorized Official
Title or Position	:	DHA UBO
Name	:	JEN LEWANDOWSKI
Credential	:
Telephone Number	:	703-817-4030

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	06/17/2025

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