MEDICARE: 23D MEDGRP-MOODY

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	1689773350	OTHER	GA	ASSOCIATED PHARMACY NPI
2	1142784	OTHER	GA	NCPDP

General Provider Information

NPI Number	:	1316907744
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	23D MEDGRP-MOODY

Provider Business Mailing Address
First Line	:	3278 MITCHELL BLVD
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699-1500
Country	:	US
Telephone Number	:	229-257-3041
Fax Number	:	229-257-5528

Provider Business Practice Location Address
First Line	:	3278 MITCHELL BLVD
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699-1500
Country	:	US
Telephone Number	:	229-257-3041
Fax Number	:	229-257-5528

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

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	06/16/2025

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Directions to “23D MEDGRP-MOODY ” Practice Location

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