1053654814 NPI number — MR. GBENGA ADEYEMI ADEYEYE PA-C

Table of content: MR. GBENGA ADEYEMI ADEYEYE PA-C (NPI 1053654814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053654814 NPI number — MR. GBENGA ADEYEMI ADEYEYE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADEYEYE
Provider First Name:
GBENGA
Provider Middle Name:
ADEYEMI
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1053654814
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1838 GREENE TREE RD
Provider Second Line Business Mailing Address:
STE 135
Provider Business Mailing Address City Name:
PIKESVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21208-7108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-486-6173
Provider Business Mailing Address Fax Number:
410-559-9460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1838 GREENE TREE RD
Provider Second Line Business Practice Location Address:
STE 135
Provider Business Practice Location Address City Name:
PIKESVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21208-7108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-486-6173
Provider Business Practice Location Address Fax Number:
410-559-9460
Provider Enumeration Date:
03/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  C05998 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 0110004213 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 10106951P . This is a "SENTARA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10106951P . This is a "OPTIMA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10112734P . This is a "SENTARA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 493474 . This is a "BCBSVA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1053654814 . This is a "TRICARE PRIME NETWORK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 178PY . This is a "BCBSNC" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10112734P . This is a "OPTIMA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1053654814 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01192419 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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