Provider Demographics
NPI:1275581415
Name:BRANCH MEDICAL CLINIC PORTSMOUTH
Entity Type:Organization
Organization Name:BRANCH MEDICAL CLINIC PORTSMOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DHA FINANCIAL 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 1:402 GOODRICH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03804
Mailing Address - Country:US
Mailing Address - Phone:207-438-1959
Mailing Address - Fax:207-438-3860
Practice Address - Street 1:402 GOODRICH AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03804-5000
Practice Address - Country:US
Practice Address - Phone:207-438-1959
Practice Address - Fax:207-438-3860
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HEALTH CLINIC NEW ENGLAND
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-04
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient