1174625057 NPI number — BETHEL MEDICAL CLINIC CHARTERED

Table of content: (NPI 1174625057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174625057 NPI number — BETHEL MEDICAL CLINIC CHARTERED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHEL MEDICAL CLINIC CHARTERED
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:
1174625057
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7325 HANOVER PKWY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
GREENBELT
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20770-3618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-345-3966
Provider Business Mailing Address Fax Number:
301-982-2937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7325 HANOVER PKWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GREENBELT
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20770-3618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-345-3966
Provider Business Practice Location Address Fax Number:
301-982-2937
Provider Enumeration Date:
09/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OBADINA
Authorized Official First Name:
BABAJIDE
Authorized Official Middle Name:
AYODEJI
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
301-345-3966

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 127041900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: KP71BE . This is a "CAREFIRST BCBS GROUP #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: C500 . This is a "CAREFIRSTBCBS DC GROUP #" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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