Organization
12TH MEDICAL GROUP RANDOLPH
Active
Other names
Randolph AFB Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
SERENA LYNN HANSKEN (AIR FORCE UNIFORM BUSINESS OFFICE)
(703) 588-6419
Entity
Organization
Contact information
Practice address
221 3RD ST W, BLDG 1040, RANDOLPH A F B, TX 78150-4800
(210) 652-2420
(210) 652-6571
Mailing address
221 3RD ST W, BLDG 1040, RANDOLPH A F B, TX 78150-4800
(210) 652-2420
(210) 652-6571
Taxonomy
Speciality
Code
Description
License number
State
261QM1100X
Military/U.S. Coast Guard Outpatient Clinic/Center
Primary
—
—
261QM1101X
Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center
—
—
332000000X
Military/U.S. Coast Guard Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4512908
NCPDP
TX
Enumeration date
02/15/2006
Last updated
11/15/2010
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