Healthcare Provider Details

I. General information

NPI: 1902955420
Provider Name (Legal Business Name): KIMBROUGH ACC MILITARY MTF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 OAKINGTON ST
ABERDEEN PROVING GROUND MD
21005-5131
US

IV. Provider business mailing address

2480 LLEWELLYN AVE CDR USAMEDDAC MCXR-BD STE 5800
FORT MEADE MD
20755-7081
US

V. Phone/Fax

Practice location:
  • Phone: 410-278-1824
  • Fax: 410-278-1779
Mailing address:
  • Phone: 301-677-8800
  • 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
# 2
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code341800000X
TaxonomyMilitary/U.S. Coast Guard Transport
License Number
License Number State

VIII. Authorized Official

Name: TERRI KIMBROW
Title or Position: UBO MANAGER
Credential:
Phone: 301-677-8512