# 12TH MEDICAL GROUP RANDOLPH

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Randolph AFB Clinic
- **Organization subpart:** No

## Provider details

- **NPI number:** 1316911597
- **Authorized official:** SERENA LYNN HANSKEN (AIR FORCE UNIFORM BUSINESS OFFICE)
- **Authorized official phone:** (703) 588-6419

## Contact information

- **Practice address:** 221 3RD ST W, BLDG 1040, RANDOLPH A F B, TX 78150-4800
- **Practice address phone:** (210) 652-2420
- **Practice address fax:** (210) 652-6571
- **Mailing address:** 221 3RD ST W, BLDG 1040, RANDOLPH A F B, TX 78150-4800
- **Mailing address phone:** (210) 652-2420
- **Mailing address fax:** (210) 652-6571

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM1100X | Military/U.S. Coast Guard Outpatient Clinic/Center | — | NULL | Yes |
| 261QM1101X | Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center | — | NULL | — |
| 332000000X | Military/U.S. Coast Guard Pharmacy | — | NULL | — |

## Other

- **Enumeration date:** 02/15/2006
- **Last updated:** 11/15/2010