366 MEDICAL GROUP SGSBF (NPI# 1144636515) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1144636515 |
| Entity Type | Organization |
| Organization Name | 366 MEDICAL GROUP SGSBF |
| Other Organization Name | DOD MT HOME EPHCY |
| Practice Address |
90 Hope Dr Bldg 6000 Mountain Home Afb ID 83648-1062 |
| Mailing Address |
366 Medical Group Sgsbf 90 Hope Dr. Bldg. 6000 Mtn Home Afb ID 83648-1062 |
| Practice Telephone | 2088287521 |
| Practice Fax Number | 2088287676 |
| Mailing Telephone | 2088287521 |
| Mailing Fax Number | 2088287676 |
| Enumeration Date | 2014-07-07 |
| Last Update Date | 2016-02-09 |
| Authorized Official Name | HECTOR MORALES (CHIEF DHA PASS) |
| Authorized Official Telephone | 2105366650 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 333600000X | Pharmacy | Suppliers | ||
| Y | 332000000X | Military/U.S. Coast Guard Pharmacy | Suppliers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| PK | 2146667 | 01 |
| Other Name | Type Code |
|---|---|
| DoD MT HOME ePhcy | Doing Business As Name - Organization |
| Street Address |
90 HOPE DR BLDG 6000 |
| City | MOUNTAIN HOME AFB |
| State | ID |
| Zip Code | 83648-1062 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1023007846 | Craig Loyd Folsom | Dentist | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648 | 2005-10-14 |
| 1598378614 | Whitney Mark Galloway | Physician Assistant | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648-1062 | 2020-08-28 |
| 1457908360 | Le Ann Marie Egan | Psychologist | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648-1062 | 2019-08-26 |
| 1639725286 | Kadeesh Mcnaught | Dental Assistant | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648-1062 | 2019-08-09 |
| 1982259875 | David J Emert | Dental Assistant | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648-1062 | 2019-08-07 |
| 1568016103 | Dylan Broadwater | Pharmacist | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648-1062 | 2019-07-31 |
| 1700381175 | Erin Siebert | Military Health Care Provider | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648-1062 | 2018-03-28 |
| 1538684915 | Emily Frieda Foxton | Physical Therapist | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648-1062 | 2017-08-07 |
| 1598298135 | Zack Hunter | Military Health Care Provider | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648-1062 | 2017-04-11 |
| 1922456979 | Jakob Kamilow | Counselor | 90 Hope Dr Bldg 6000, Mountain Home Afb, ID 83648-1062 | 2016-06-01 |
| Find all providers in the same location | ||||
| 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 |
| 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 |
| 1548796527 | Derek J Dutson | Dentist | 90 Hope Dr, Mountain Home Afb, ID 83648 | 2017-05-11 |
| Find all providers in zip 83648 | ||||
| Taxonomy Code | 332000000X |
| Grouping | Suppliers |
| Classification | Military/U.S. Coast Guard Pharmacy |
| A Department of Defense (DoD) or U.S. Coast Guard entity whose primary function is to store, prepare and dispense pharmaceuticals and other associated items to Uniformed Services beneficiaries. These pharmacies may be associated with a DoD or U.S. Coast Guard clinic, DoD Hospital or freestanding. Usually associated with outpatient services. |
| Notes: Source: TRICARE Management Activity Uniform Business Office User’s Guide [1/1/2005: new; 7/1/2006: modified title, modified definition] |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1801959473 | Mt Home Refill Phcy | Military/U.S. Coast Guard Pharmacy | 90 Hope Dr, Mountain Home Afb, ID 83648 | 2006-12-18 |
| City | MOUNTAIN HOME AFB |
| Zip Code | 83648 |
Please comment or provide details below to improve the information on 366 MEDICAL GROUP SGSBF.
| 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.