Provider Demographics
NPI:1215994660
Name:316TH MEDGRP-MALCOLM GROW
Entity type:Organization
Organization Name:316TH MEDGRP-MALCOLM GROW
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DHA FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:1060 W PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762-6602
Mailing Address - Country:US
Mailing Address - Phone:240-857-8658
Mailing Address - Fax:240-857-7700
Practice Address - Street 1:1060 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-6602
Practice Address - Country:US
Practice Address - Phone:240-857-8658
Practice Address - Fax:240-857-7700
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:316TH MEDGRP-MALCOLM GROW
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-28
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
Yes261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21-25373OtherNCPDP