Provider Demographics
NPI:1730386327
Name:BRANCH MEDICAL CLINIC NTC SAN DIEGO
Entity type:Organization
Organization Name:BRANCH MEDICAL CLINIC NTC SAN DIEGO
Other - Org Name:<UNAVAIL>
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 1:2051 CUSHING ROAD
Mailing Address - Street 2:BLDG 624
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-0000
Mailing Address - Country:US
Mailing Address - Phone:619-524-0173
Mailing Address - Fax:619-524-0118
Practice Address - Street 1:2051 CUSHING ROAD
Practice Address - Street 2:BLDG 624
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-0000
Practice Address - Country:US
Practice Address - Phone:619-524-0173
Practice Address - Fax:619-524-0118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL MEDICAL CENTER SAN DIEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-28
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient