Provider Demographics
NPI:1487053435
Name:42ND MEDICAL GROUP
Entity type:Organization
Organization Name:42ND MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF DHA PASS
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-536-6650
Mailing Address - Street 1:USAF-MAXWELL HOSPITAL/SGL
Mailing Address - Street 2:300 SOUTH TWINING ST. BLDG. 760
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36112-0000
Mailing Address - Country:US
Mailing Address - Phone:334-953-9333
Mailing Address - Fax:334-953-5272
Practice Address - Street 1:300 TWINING ST
Practice Address - Street 2:
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112-6027
Practice Address - Country:US
Practice Address - Phone:334-953-9333
Practice Address - Fax:334-953-5272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147340OtherPK