Provider Demographics
NPI:1730254152
Name:KIMBROUGH ACC MILITARY MTF
Entity type:Organization
Organization Name:KIMBROUGH ACC MILITARY MTF
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:UBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-677-8512
Mailing Address - Street 1:2480 LLEWELLYN AVE
Mailing Address - Street 2:CDR USAMEDDAC MCXR-BD STE 5800
Mailing Address - City:FORT MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-7081
Mailing Address - Country:US
Mailing Address - Phone:301-677-8253
Mailing Address - Fax:
Practice Address - Street 1:450 GIBNER RD
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-5090
Practice Address - Country:US
Practice Address - Phone:717-245-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIMBROUGH ACC MILITARY MTF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AN2598588OtherMEDCO
1164507703OtherPARENT FACILITY NPI
OTH000Medicare UPIN
AN2598588OtherMEDCO