1992073084 NPI number — BENJAMIN A. ADEWALE MD PC

Table of content: (NPI 1992073084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992073084 NPI number — BENJAMIN A. ADEWALE MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENJAMIN A. ADEWALE MD PC
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:
RIVERSIDE MENTAL AND MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
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:
1992073084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 S QUAKER LN
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22314-4585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-257-4398
Provider Business Mailing Address Fax Number:
703-823-4407

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 S QUAKER LN
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22314-4585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-257-4398
Provider Business Practice Location Address Fax Number:
703-823-4407
Provider Enumeration Date:
12/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ADEWALE
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
703-569-8028

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MD22004 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 031768500 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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