Provider Demographics
NPI:1972564243
Name:BRANCH MEDICAL CLINIC GROTON
Entity type:Organization
Organization Name:BRANCH MEDICAL CLINIC GROTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUMED UBO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5600
Mailing Address - Country:US
Mailing Address - Phone:860-694-2556
Mailing Address - Fax:860-694-4843
Practice Address - Street 1:1 WAHOO AVE
Practice Address - Street 2:BOX 600, CODE 42G
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-2324
Practice Address - Country:US
Practice Address - Phone:860-694-2556
Practice Address - Fax:860-694-4843
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HEALTH CLINIC NEW ENGLAND
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-28
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT261QM1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient