1235584384 NPI number — OUTREACH MD LLC

Table of content: (NPI 1235584384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235584384 NPI number — OUTREACH MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUTREACH MD LLC
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:
1235584384
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2124 4TH AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35233-2204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-279-8981
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 NORTHVIEW DR
Provider Second Line Business Practice Location Address:
SUITE 501
Provider Business Practice Location Address City Name:
BOWIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20716-2604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-220-1111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ABDESHAHIAN
Authorized Official First Name:
EHSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
405-306-0384

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0714704 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com