Basic Information
| Provider Information | |||||||||
| NPI: | 1508072281 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIMBROUGH ACC MILITARY MTF | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TMC ABERDEEN PROVING GROUND | ||||||||
| 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: | 2501 OAKINGTON ST | ||||||||
| Address2: | |||||||||
| City: | ABERDEEN PROVING GROUND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210055131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016778253 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 08/09/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIMBROW | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C, UBO | ||||||||
| AuthorizedOfficialTelephone: | 3016778512 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KIMBROUGH ACC MILITARY MTF | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | OTHER |