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General NPI Number Information
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NPI Number | 1215994660
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Entity Type | Organization
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Legal Business Name | 316TH MEDGRP-MALCOLM GROW
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Dates
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Enumeration Date | 04/28/2006
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Last Update Date | 03/12/2025
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Provider Practice Location Address
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Address Line | 1060 W PERIMETER RD
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City | JB ANDREWS
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State | MD
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Zip | 20762-6602
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Country | US
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Telephone | 240-857-8658
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Fax | 240-857-7700
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Provider Business Mailing Address
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Address Line | 1060 W PERIMETER RD
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City | JB ANDREWS
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State | MD
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Zip | 20762-6602
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Country | US
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Telephone | 240-857-8658
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Fax | 240-857-7700
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Authorized Official
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Title or Position | DHA FINANCIAL MANAGER
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Name | WILLIAM MICHAEL CONDON
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Credential |
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Telephone | 240-401-3643
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1100X
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Taxonomy Name | Military/U.S. Coast Guard Outpatient Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1101X
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Taxonomy Name | Military and U.S. Coast Guard Ambulatory Procedure Clinic/Center
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License Number |
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License Number State |
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