366TH Medgrp-Mountain Home

Primary specialty

Military and U.S. Coast Guard Ambulatory Procedure Clinic/CenterTaxonomy code 261QM1101X

Legal business name

366TH MEDGRP-MOUNTAIN HOME

Practice address

90 Hope Drive BLDG 6000
366 Medical Group
Mountain Home Afb, ID 83648-1062

Phone

(208) 828-7470

Fax

(208) 828-2753

NPI assigned

Feb 17, 2006

Organization subpart

Yes

Parent organization

366TH MEDGRP-MOUNTAIN HOMEAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jen Lewandowski

Title

Dha Ubo

Phone

(703) 817-4030

Specialties & licenses 3

Addresses

Other identifiers 2

Tax ID family

366TH Medgrp-Mountain Home2 organizations share this tax ID, including this one

Part of

366TH Medgrp-Mountain Home

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• 366TH Medgrp-Mountain Home

  • Military/U.S. Coast Guard Pharmacy
  • Mountain Home Afb, ID
  • NPI 1144636515
  NPD tax ID

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1140134400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750118400000",
    "number": "1063487791",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "90 HOPE DRIVE BLDG 6000",
            "address_2": "366 MEDICAL GROUP SGSR",
            "city": "MOUNTAIN HOME AFB",
            "state": "ID",
            "postal_code": "836481062",
            "telephone_number": "208-828-7470",
            "fax_number": "208-828-2753"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "90 HOPE DRIVE BLDG 6000",
            "address_2": "366 MEDICAL GROUP",
            "city": "MOUNTAIN HOME AFB",
            "state": "ID",
            "postal_code": "836481062",
            "telephone_number": "208-828-7470",
            "fax_number": "208-828-2753"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "366TH MEDGRP-MOUNTAIN HOME",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "366TH MEDGRP-MOUNTAIN HOME",
        "enumeration_date": "2006-02-17",
        "last_updated": "2025-06-17",
        "certification_date": "2025-06-17",
        "status": "A",
        "authorized_official_last_name": "LEWANDOWSKI",
        "authorized_official_first_name": "JEN",
        "authorized_official_title_or_position": "DHA UBO",
        "authorized_official_telephone_number": "703-817-4030"
    },
    "taxonomies": [
        {
            "code": "261QM1100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Military/U.S. Coast Guard Outpatient",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1101X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Military and U.S. Coast Guard Ambulatory Procedure",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "332000000X",
            "taxonomy_group": "",
            "desc": "Military/U.S. Coast Guard Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8072078",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "1306845",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• 366TH Medgrp-Mountain Home
• 366TH Medical Group SGSL
• Andrew Alton
• Nathan Lee Anderson, O.D.
• Ronald Wesley Bailey, M.D.

• Clinic/Center in Mountain Home Afb, ID
• Providers in Mountain Home Afb, ID by specialty
• Clinic/Center in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.