Basic Information
| Provider Information | |||||||||
| NPI: | 1164507703 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIMBROUGH ACC MILITARY MTF | ||||||||
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| OtherOrganizationName: | KIMBROUGH AMBULATORY CARE CENTER-MEADE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2480 LLEWELLYN AVE | ||||||||
| Address2: | CDR USAMEDDAC MCXR-BD STE 5800 | ||||||||
| City: | FORT MEADE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207557081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016778800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2480 LLEWELLYN AVE | ||||||||
| Address2: | |||||||||
| City: | FORT MEADE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207555800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016778800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | KIMBROW | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | UBO MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3016778512 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient | 332000000X | N | Suppliers | Military/U.S. Coast Guard Pharmacy | 261QM1101X | Y | Ambulatory Health Care Facilities | Clinic/Center | Military and U.S. Coast Guard Ambulatory Procedure |
ID Information
| ID | Type | State | Issuer | Description | 02DT | 01 | BCBS FEDERAL | OTHER | AN2598588 | 01 | MEDCO | OTHER | 1447357298 / 2125284 | 01 | PHARMACY NPI/NCPDP | OTHER |