Provider Demographics
NPI:1073712824
Name:BRANCH MEDICAL CLINIC CAMP SMITH MEDICAL ANNEX
Entity Type:Organization
Organization Name:BRANCH MEDICAL CLINIC CAMP SMITH MEDICAL ANNEX
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 1:480 CENTRAL AVE
Mailing Address - Street 2:CODE 02
Mailing Address - City:PEARL HARBOR
Mailing Address - State:HI
Mailing Address - Zip Code:96860-4908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:CODE 02
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:808-474-2239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HEALTH CLINIC HAWAII
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-12
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient