Provider Demographics
NPI:1023400256
Name:BRANCH MEDICAL CLINIC MCAS MIRAMAR
Entity Type:Organization
Organization Name:BRANCH MEDICAL CLINIC MCAS MIRAMAR
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:BAUER RD
Mailing Address - Street 2:BLDG 2496
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92145-0001
Mailing Address - Country:US
Mailing Address - Phone:858-577-4656
Mailing Address - Fax:
Practice Address - Street 1:BAUER RD
Practice Address - Street 2:BLDG 2496
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92145-0001
Practice Address - Country:US
Practice Address - Phone:858-577-4656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL MEDICAL CENTER SAN DIEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-25
Last Update Date:2017-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient