Provider Demographics
NPI:1942286224
Name:21ST MEDGRP-PETERSON
Entity type:Organization
Organization Name:21ST MEDGRP-PETERSON
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 1:559 VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1541
Mailing Address - Country:US
Mailing Address - Phone:719-556-1250
Mailing Address - Fax:
Practice Address - Street 1:559 VINCENT ST
Practice Address - Street 2:
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1541
Practice Address - Country:US
Practice Address - Phone:719-556-1250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:21ST MEDGRP-PETERSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-19
Last Update Date:2025-06-12
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
CO1548369259OtherNPPES
CO06-16788OtherNCPDP