MEDICARE: WALSON MEDICAL SUPPORT ELEMENT

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	261QM1102X	Military Outpatient Operational (Transportable) Component Clinic/Center	F333963-1	NM

General Provider Information

NPI Number	:	1154474419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALSON MEDICAL SUPPORT ELEMENT

Provider Business Mailing Address
First Line	:	1562 MARINE PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-3414
Country	:	US
Telephone Number	:	347-733-9938
Fax Number	:

Provider Business Practice Location Address
First Line	:	5631 BALTIMORE AVE
Second Line	:
City	:	FT. DIX
State	:	NJ
Zip	:	08640-0000
Country	:	US
Telephone Number	:	609-562-5419
Fax Number	:

Authorized Official
Title or Position	:	DCCS
Name	:	ALBERT MARTINS
Credential	:	MD
Telephone Number	:	609-562-5419

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	08/22/2020

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