366 MEDICAL GROUP (NPI# 1063487791) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1063487791 |
| Entity Type | Organization |
| Organization Name | 366 MEDICAL GROUP |
| Practice Address |
90 Hope Drive Bldg 6000 366 Medical Group Mountain Home Afb ID 83648-1062 |
| Mailing Address |
90 Hope Drive Bldg 6000 366 Medical Group Sgsr Mountain Home Afb ID 83648-1062 |
| Practice Telephone | 2088287470 |
| Practice Fax Number | 2088282753 |
| Mailing Telephone | 2088287470 |
| Mailing Fax Number | 2088282753 |
| Enumeration Date | 2006-02-17 |
| Last Update Date | 2017-11-08 |
| Authorized Official Name | STEVEN R WARD (COMMANDER) |
| Authorized Official Telephone | 2088287600 |
| Authorized Official Credential | M.D. |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 261QM1100X |
Clinic/Center Specialization: Military/U.S. Coast Guard Outpatient |
Ambulatory Health Care Facilities | ||
| N | 332000000X | Military/U.S. Coast Guard Pharmacy | Suppliers | ||
| Y | 261QM1101X |
Clinic/Center Specialization: Military and U.S. Coast Guard Ambulatory Procedure |
Ambulatory Health Care Facilities |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| ID | NCPDP | 1306845 | 01 |
| ID | 8072078 | 05 |
| Street Address |
90 HOPE DRIVE BLDG 6000 366 MEDICAL GROUP |
| City | MOUNTAIN HOME AFB |
| State | ID |
| Zip Code | 83648-1062 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1851528392 | Amy Jo Glover | Military Health Care Provider | 90 Hope Dr. Bldg 6000, Mountain Home, ID 83648 | 2009-06-11 |
| 1306051065 | Thomas Michael Smith | Social Worker | 90 Hope Dr Bldg 1900, Mountain Home Afb, ID 83648 | 2007-05-14 |
| 1316005143 | Ronald Wesley Bailey | Radiology | Mountain Home Afb Medical Group, 90 Hope Drive, Building 6000, Mountain Home Afb, ID 83648 | 2006-12-05 |
| 1992780597 | Randall Jay Moore | Preventive Medicine | 366mdg/sgpf, 90 Hope Drive; Bldg 6000, Mountain Home Afb, ID 83648 | 2005-12-07 |
| 1356325666 | Joseph Carroll Skinner Jr. | Nurse Anesthetist, Certified Registered | 366 Mdos, Sgosa, 90 Hope Drive, Mountain Home Afb, ID 83648 | 2005-11-30 |
| 1023007846 | Craig Loyd Folsom | Dentist | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648 | 2005-10-14 |
| 1477547271 | Ron Stumbo | Pharmacist | Mountain Home Afb, Mountain Home Afb, ID 83648 | 2005-09-07 |
| 1154315943 | Georgette Ann Trezvant | Social Worker | 366 Medical Operations Squadron, 90 Hope Drive, Bldg 6000, Mt. Home Air Force Base, ID 83648 | 2005-09-07 |
| 1265948897 | Alyse Marie Denittis | Physician Assistant | 90 Hope Dr, Mountain Home Afb, ID 83648 | 2017-12-19 |
| 1891224473 | Jared Getzlaff | Military Health Care Provider | 90 Hope Dr, Mountain Home Afb, ID 83648 | 2017-06-07 |
| Find all providers in zip 83648 | ||||
| Taxonomy Code | 261QM1101X |
| Grouping | Ambulatory Health Care Facilities |
| Classification | Clinic/Center |
| Specialization | Military and U.S. Coast Guard Ambulatory Procedure |
| That part of a "fixed" (non-temporary, non-deployed) DoD or Coast Guard entity furnishing surgical procedures requiring medically supervised recovery. Similar to a civilian ambulatory surgical center. May be in shared resources with a DoD or Coast Guard Clinic or a DoD Hospital. Does not include items issued directly to a patient from an outpatient pharmacy or patient transport. Includes initial "take home" pharmaceuticals. |
| Notes: Source: TRICARE Management Activity Uniform Business Office User’s Guide [1/1/2005: title modified, definition added; 7/1/2006 title modified, definition modified] |
| City | MOUNTAIN HOME AFB |
| Zip Code | 83648 |
Please comment or provide details below to improve the information on 366 MEDICAL GROUP.
| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.