Healthcare Provider Details

I. General information

NPI: 1114432085
Provider Name (Legal Business Name): BRANCH MEDICAL CLINIC KINGS BAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 12/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 USS JAMES MADISON RD
KINGS BAY GA
31547-2531
US

IV. Provider business mailing address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

V. Phone/Fax

Practice location:
  • Phone: 912-573-6398
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM M CONDON
Title or Position: BUMED UBO
Credential:
Phone: 240-401-3643