Provider Demographics
NPI:1700846813
Name:22D MEDGRP-MCCONNELL
Entity type:Organization
Organization Name:22D MEDGRP-MCCONNELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AIR FORCE UBO ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-681-7613
Mailing Address - Street 1:57950 LEAVENWORTH ST 6E4
Mailing Address - Street 2:
Mailing Address - City:MCCONNELL AFB
Mailing Address - State:KS
Mailing Address - Zip Code:67221-3506
Mailing Address - Country:US
Mailing Address - Phone:316-759-5000
Mailing Address - Fax:316-759-5038
Practice Address - Street 1:57950 LEAVENWORTH ST 6E4
Practice Address - Street 2:
Practice Address - City:MCCONNELL AFB
Practice Address - State:KS
Practice Address - Zip Code:67221-3506
Practice Address - Country:US
Practice Address - Phone:316-759-5000
Practice Address - Fax:316-759-5038
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:22D MEDGRP-MCCONNELL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-23
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS17-17517OtherNCPDP