Provider Demographics
NPI:1316911597
Name:12TH MEDICAL GROUP RANDOLPH
Entity type:Organization
Organization Name:12TH MEDICAL GROUP RANDOLPH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AIR FORCE UNIFORM BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HANSKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-588-6419
Mailing Address - Street 1:221 3RD ST W
Mailing Address - Street 2:BLDG 1040
Mailing Address - City:RANDOLPH A F B
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4800
Mailing Address - Country:US
Mailing Address - Phone:210-652-2420
Mailing Address - Fax:210-652-6571
Practice Address - Street 1:221 3RD ST W
Practice Address - Street 2:BLDG 1040
Practice Address - City:RANDOLPH A F B
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:210-652-2420
Practice Address - Fax:210-652-6571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4512908OtherNCPDP