Provider Demographics
NPI:1922208487
Name:BRANCH MEDICAL CLINIC NTTC PENSACOLA
Entity Type:Organization
Organization Name:BRANCH MEDICAL CLINIC NTTC PENSACOLA
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 1:6000 W HIGHWAY 98
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32512-0001
Mailing Address - Country:US
Mailing Address - Phone:850-505-6309
Mailing Address - Fax:850-505-6908
Practice Address - Street 1:765 6TH ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32511-5119
Practice Address - Country:US
Practice Address - Phone:850-452-6326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HOSPITAL PENSACOLA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-23
Last Update Date:2017-11-14
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
FLVAD000Medicare UPIN