Provider Demographics
NPI:1205800109
Name:2 MDSS SGSR
Entity type:Organization
Organization Name:2 MDSS SGSR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEFENSE HEALTH AGENCY DHA FINANCIAL
Authorized Official - Prefix:
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 1:243 CURTISS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BARKSDALE AFB
Mailing Address - State:LA
Mailing Address - Zip Code:71110-2425
Mailing Address - Country:US
Mailing Address - Phone:318-456-6055
Mailing Address - Fax:318-456-6065
Practice Address - Street 1:243 CURTISS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BARKSDALE AFB
Practice Address - State:LA
Practice Address - Zip Code:71110-2425
Practice Address - Country:US
Practice Address - Phone:318-456-6055
Practice Address - Fax:318-456-6065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1929299OtherNCPDP