Provider Demographics
NPI:1073729745
Name:KIMBROUGH ACC MILITARY MTF
Entity Type:Organization
Organization Name:KIMBROUGH ACC MILITARY MTF
Other - Org Name:OHC EDGEWOOD ARS
Other - Org Type:Doing Business As
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 1:2501 OAKINGTON ST
Practice Address - Street 2:BUILDING E-4110
Practice Address - City:ABERDEEN PROVING GROUND
Practice Address - State:MD
Practice Address - Zip Code:21005-5131
Practice Address - Country:US
Practice Address - Phone:410-278-1824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIMBROUGH ACC MILITARY MTF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-16
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164507703OtherPARENT FACILITY NPI
VAD000Medicare UPIN
OTH000Medicare UPIN