Provider Demographics
NPI:1841498417
Name:BRANCH MEDICAL CLINIC INDIAN HEAD
Entity type:Organization
Organization Name:BRANCH MEDICAL CLINIC INDIAN HEAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NAVY MEDICINE UBO PROGRAM 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 1:4141 W WILSON RD
Mailing Address - Street 2:SUITE105
Mailing Address - City:INDIAN HEAD
Mailing Address - State:MD
Mailing Address - Zip Code:20640-5162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4141 W WILSON RD
Practice Address - Street 2:SUITE105
Practice Address - City:INDIAN HEAD
Practice Address - State:MD
Practice Address - Zip Code:20640-5162
Practice Address - Country:US
Practice Address - Phone:301-744-4601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HEALTH CLINIC PATUXENT RIVER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-05
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient