366TH MEDGRP-MOUNTAIN HOME NPI 1063487791

NPI Information

NPI: 1063487791
Provider Name: 366TH MEDGRP-MOUNTAIN HOME
Classification: Clinic/Center - 261QM1101X
Specialization: Military and U.S. Coast Guard Ambulatory Procedure
Entity Type: Organization
Address: 90 HOPE DRIVE BLDG 6000
366 MEDICAL GROUP
MOUNTAIN HOME AFB, ID
ZIP 83648
Phone: (208) 828-7470

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NPI Details

366TH MEDGRP-MOUNTAIN HOME is a military and u.s. coast guard ambulatory procedure clinic center in Mountain Home Afb, ID. The provider is 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. 366TH MEDGRP-MOUNTAIN HOME NPI is 1063487791. The provider is registered as an organization entity type.

The provider's business location address is:

90 HOPE DRIVE BLDG 6000
366 MEDICAL GROUP
MOUNTAIN HOME AFB, ID
ZIP 83648-062
Phone: (208) 828-7470
Fax: (208) 828-2753

The provider's authorized official is Jen Lewandowski .
The authorized official title is Dha Ubo and has the following contact phone number (703) 817-4030.

The enumeration date for this NPI number is 2/17/2006 and was last updated on 6/17/2025.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	Primary
1	261QM1100X	Clinic/Center	Military/U.S. Coast Guard Outpatient	No
2	332000000X	Military/U.S. Coast Guard Pharmacy		No
3	261QM1101X	Clinic/Center	Military and U.S. Coast Guard Ambulatory Procedure	Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	8072078	MEDICAID	IDAHO
2	1306845	OTHER	IDAHO	NCPDP

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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