1215093786 NPI number — BAYSIDE BEHAVIORAL HEALTH CLINIC OF

Table of content: (NPI 1215093786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215093786 NPI number — BAYSIDE BEHAVIORAL HEALTH CLINIC OF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYSIDE BEHAVIORAL HEALTH CLINIC OF
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:
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:
1215093786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLICOTT CITY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21042-0250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-292-4559
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2444 SOLOMONS ISLAND RD STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-3723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-292-4559
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OGUNMEFUN
Authorized Official First Name:
ADELEKE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
410-292-4559

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0804X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0805X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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