1215919980 NPI number — DR. IBRAHIM ELSAMANOUDI M.D.

Table of content: DR. IBRAHIM ELSAMANOUDI M.D. (NPI 1215919980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215919980 NPI number — DR. IBRAHIM ELSAMANOUDI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELSAMANOUDI
Provider First Name:
IBRAHIM
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1215919980
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 E. UNIVERSITY PARKWAY
Provider Second Line Business Mailing Address:
33RD STREET PROFESSIONAL BUILDING, SUITE #425
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21218-2829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-554-2724
Provider Business Mailing Address Fax Number:
410-261-8598

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 E UNIVERSITY PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21218-2829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-554-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/17/2005

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: 207L00000X , with the licence number:  D0032500 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207LP2900X , with the licence number: D0032500 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 279881600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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