Provider Demographics
NPI:1033315080
Name:BRANCH MEDICAL CLINIC BANCROFT HALL
Entity Type:Organization
Organization Name:BRANCH MEDICAL CLINIC BANCROFT HALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NAVY MEDICINE UBO PROGRAM MANAGER
Authorized Official - Prefix:MR
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 1:8901 WISCONSIN AVE
Mailing Address - Street 2:PSC BOX 509 CODE 6300
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-0001
Mailing Address - Country:US
Mailing Address - Phone:301-295-4934
Mailing Address - Fax:301-295-1299
Practice Address - Street 1:121 BLAKE RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21402-1300
Practice Address - Country:US
Practice Address - Phone:410-293-1771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HEALTH CLINIC ANNAPOLIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-26
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient