355 MDG (NPI# 1245210384) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1245210384 |
| Entity Type | Organization |
| Organization Name | 355 MDG |
| Practice Address |
4175 S Alamo Ave Tucson AZ 85707-6097 |
| Practice Telephone | 5202281506 |
| Practice Fax Number | 5202280183 |
| Mailing Telephone | 5202281506 |
| Mailing Fax Number | 5202280183 |
| Enumeration Date | 2006-01-17 |
| Last Update Date | 2010-11-15 |
| Authorized Official Name | SERENA LYNN HANSKEN (AIR FORCE UNIFORM BUSINESS OFFICE) |
| Authorized Official Telephone | 7035886419 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 332000000X | Military/U.S. Coast Guard Pharmacy | Suppliers | ||
| N | 261QM1101X |
Clinic/Center Specialization: Military and U.S. Coast Guard Ambulatory Procedure |
Ambulatory Health Care Facilities | ||
| Y | 261QM1100X |
Clinic/Center Specialization: Military/U.S. Coast Guard Outpatient |
Ambulatory Health Care Facilities |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| AZ | NCPDP | 0322103 | 01 |
| Street Address |
4175 S ALAMO AVE |
| City | TUCSON |
| State | AZ |
| Zip Code | 85707-6097 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1760956387 | Kyle Lynn Craver | Military Health Care Provider | 4175 S Alamo Ave, Tucson, AZ 85707 | 2019-01-16 |
| 1396216099 | Laura Bette | Social Worker | 4175 S Alamo Ave, Tucson, AZ 85707-4402 | 2018-12-07 |
| 1679048250 | Lam T Chung | Pharmacist | 4175 S Alamo Ave, Tucson, AZ 85707-4402 | 2018-10-10 |
| 1811477235 | Alan Thatcher Price | Military Health Care Provider | 4175 S Alamo Ave, Tucson, AZ 85707-4402 | 2018-08-15 |
| 1841776101 | Kimberly Johnson | Nurse Practitioner | 4175 S Alamo Ave, Tucson, AZ 85707-4402 | 2018-07-19 |
| 1457868598 | Kristina Marie Linden | Social Worker | 4175 S Alamo Ave, Tucson, AZ 85707-4402 | 2018-01-10 |
| 1235668054 | Joseph Anthony Everett | Dentist | 4175 S Alamo Ave, Tucson, AZ 85707-4402 | 2017-06-06 |
| 1407205743 | Eun Soo David Park | Family Medicine | 4175 S Alamo Ave, Tucson, AZ 85707 | 2016-06-07 |
| 1477907590 | Vanessa F Scheirer | Physical Therapist | 4175 S Alamo Ave, Tucson, AZ 85707-4402 | 2016-04-14 |
| 1164883104 | Marc Enslow | Dentist | 4175 S Alamo Ave, Tucson, AZ 85707-4402 | 2016-03-18 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1699128850 | Megan Dehaven | Specialist/Technologist | 5455 E Comanche St, Tucson, AZ 85707 | 2016-07-22 |
| 1780927954 | Ryan N Taylor | Physician Assistant | 400, 4175 S Alamo Ave, Davis-monthan Afb, AZ 85707 | 2013-04-05 |
| 1154658839 | Alisha A Marchetti | Physician Assistant | 4175 S. Alamo Avenue, 355th Mdg/mdos, Davis-monthan Afb, AZ 85707 | 2009-11-17 |
| 1851529192 | Christopher Thomas Yarbrough | Military Health Care Provider | 4625 South Phoenix Street Bldg 4843, Tucson, AZ 85707 | 2009-06-25 |
| 1144457045 | Denise Fabian | Psychiatry & Neurology | 5427 E. Madera Street, Davis Monthan Afb, AZ 85707 | 2009-06-17 |
| 1942437447 | Emerson M Earle | Military Health Care Provider | 4625 S. Phoenix St, Bld 4843, Tucson, AZ 85707 | 2009-06-11 |
| 1164657136 | Raul Romero | Military Health Care Provider | 4575 S. Phoenix St. 563rd Oss, Dmafb, AZ 85707 | 2009-05-20 |
| 1063647196 | Virginia E. Bailey | Military Health Care Provider | 4837 S Phoenix St., Rm 119 Davis-monthan Air Force Base, Tucson, AZ 85707 | 2009-05-19 |
| 1043417611 | Jacob Riis | Orthopaedic Surgery | 355 Mdg, 4175 South Alamo Ave, Tucson, AZ 85707 | 2007-06-28 |
| 1508989732 | Christopher E. Dunham | Physician Assistant | 4175 S. Alamo Ave Bldg 400, 355th Medical Group-davis Monthan Afb, Tucson, AZ 85707 | 2007-04-10 |
| Find all providers in zip 85707 | ||||
| Taxonomy Code | 261QM1100X |
| Grouping | Ambulatory Health Care Facilities |
| Classification | Clinic/Center |
| Specialization | Military/U.S. Coast Guard Outpatient |
| The Defense Health Program or U.S. Coast Guard funded "fixed" facilities or distinct parts of a facility, providing outpatient medical and dental services, primarily for Uniformed Services beneficiaries. A "fixed" facility is a non-temporary, non-deployed facility. It includes mobile specialty units such as Magnetic Resonance Imaging (MRI) units that may furnish services at the "fixed" facility. It includes, as examples, the institutional portion of outpatient encounters (except Ambulatory Procedure Visits), supplies issued (e.g., glasses, ostomy supplies, crutches), and radiology and laboratory studies. Does not include items issued directly to a patient from an outpatient pharmacy or patient transport. |
| 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] |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1306049895 | Raymond W. Bliss Army Health Center | Clinic/Center | 45005 Arizona Street, Fort Huachuca, AZ 85613 | 2007-06-11 |
| 1508069527 | Naval Hospital Camp Pendleton | Clinic/Center | Bldg 1175, Yuma, AZ 85369 | 2007-06-07 |
| 1588635098 | Usa Meddac,rwbahc | Clinic/Center | 2240 Winrow Rd, Ft Huachuca, AZ 85613-5080 | 2006-02-01 |
| 1346455391 | Weed Army Community Hospital | Clinic/Center | 301 C St, Bldg 990, Yuma, AZ 85365-9498 | 2007-05-12 |
| 1811960149 | Raymond W. Bliss Health Cemter | Clinic/Center | 2240 E. Winrow Ave., Meddac, Ft. Huachuca, AZ 85613 | 2006-02-08 |
| 1083685507 | Raymond W. Bliss Army Health Center | Clinic/Center | 2240 E. Winrow Ave, Usa Meddac, Rwbahc, Fort Huachuca, AZ 85613-7079 | 2006-02-01 |
| 1558332080 | Raymond W Bliss Army Health Center | Clinic/Center | 2240 Winrow Rd, Ft Huachuca, AZ 85613-5080 | 2006-02-01 |
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| 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.