1104824465 NPI number — DR. BAYINNAH SHABAZZ M.D.

Table of content: DR. BAYINNAH SHABAZZ M.D. (NPI 1104824465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104824465 NPI number — DR. BAYINNAH SHABAZZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHABAZZ
Provider First Name:
BAYINNAH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1104824465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1589 SULPHUR SPRING RD
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21227-2542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-536-5400
Provider Business Mailing Address Fax Number:
410-737-2168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
808 LANDMARK DR
Provider Second Line Business Practice Location Address:
SUITE 122
Provider Business Practice Location Address City Name:
GLEN BURNIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21061-4983
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-760-3588
Provider Business Practice Location Address Fax Number:
410-760-3604
Provider Enumeration Date:
07/12/2005

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: 207RN0300X , with the licence number:  D24592 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 269581200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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