Healthcare Provider Details

I. General information

NPI: 1487850541
Provider Name (Legal Business Name): BRANCH MEDICAL CLINIC ANDREWS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAN DIEGO LOOP BLDG 3282
ANDREWS AFB MD
20762-5518
US

IV. Provider business mailing address

1 SAN DIEGO LOOP BLDG 3282
ANDREWS AFB MD
20762-5518
US

V. Phone/Fax

Practice location:
  • Phone: 240-857-2865
  • 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: MR. WILLIAM MICHAEL CONDON
Title or Position: NAVY MEDICINE UBO PROGRAM MANAGER
Credential:
Phone: 240-401-3643