MEDICARE: KIMBROUGH ACC MILITARY MTF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332000000X	Military/U.S. Coast Guard Pharmacy
2	261QM1100X	Military/U.S. Coast Guard Outpatient Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1164507703	OTHER		PARENT FACILITY NPI 2 EFF 1 OCT 10

General Provider Information

NPI Number	:	1689888455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIMBROUGH ACC MILITARY MTF

Provider Business Mailing Address
First Line	:	2480 LLEWELLYN AVE
Second Line	:	CDR USAMEDDAC MCXR-BD STE 5800
City	:	FORT MEADE
State	:	MD
Zip	:	20755-7081
Country	:	US
Telephone Number	:	301-677-8800
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 3RD AVE
Second Line	:	BUILDING 58
City	:	WASHINGTON
State	:	DC
Zip	:	20319-5058
Country	:	US
Telephone Number	:	301-677-8800
Fax Number	:

Authorized Official
Title or Position	:	UBO MANAGER
Name	:	TERRI KIMBROW
Credential	:
Telephone Number	:	301-677-8512

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	04/01/2015

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