Basic Information
Provider Information | |||||||||
NPI: | 1467665877 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KIMBROUGH ACC MILITARY MTF | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AHC ANDREW RADER-MYER-HENDERSN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2480 LLEWELLYN AVE | ||||||||
Address2: | CDR USAMEDDAC MCXR-BD STE 5800 | ||||||||
City: | FORT MEADE | ||||||||
State: | MD | ||||||||
PostalCode: | 207557081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016778253 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 401 CARPENTER RD | ||||||||
Address2: |   | ||||||||
City: | FT MYER | ||||||||
State: | VA | ||||||||
PostalCode: | 222111009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016778800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2007 | ||||||||
LastUpdateDate: | 04/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KIMBROW | ||||||||
AuthorizedOfficialFirstName: | TERRI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | UBO MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3016778512 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | KIMBROUGH ACC MILITARY MTF | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X |   |   | N |   | Suppliers | Military/U.S. Coast Guard Pharmacy |   | 261QM1100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
ID Information
ID | Type | State | Issuer | Description | 1164507703 | 01 |   | PARENT FACILITY NPI 2 EFF 1 OCT 10 | OTHER |