1417369299 NPI number — FT MEADE MEDDAC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417369299 NPI number — FT MEADE MEDDAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FT MEADE MEDDAC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417369299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
KIMBROUGH ACC MILITARY MTF C/O CDR USAMEDDAC MCXR-BD
Provider Second Line Business Mailing Address:
2480 LEWELLYN AVE STE 5800
Provider Business Mailing Address City Name:
FT MEADE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20755-5129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-278-1945
Provider Business Mailing Address Fax Number:
410-278-1935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
KIRK U.S. ARMY HEALTH CLINIC
Provider Second Line Business Practice Location Address:
BLDG. 2501 OAKINGTON STREET
Provider Business Practice Location Address City Name:
ABERDEEN PROVING GROUND
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21005-5163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-278-1945
Provider Business Practice Location Address Fax Number:
410-278-1935
Provider Enumeration Date:
05/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MORALES
Authorized Official First Name:
HECTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF DHA PASS
Authorized Official Telephone Number:
210-536-6650

Provider Taxonomy Codes

  • Taxonomy code: 332000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2145946 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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