Provider Demographics
NPI:1235584384
Name:OUTREACH MD LLC
Entity Type:Organization
Organization Name:OUTREACH MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EHSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDESHAHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-306-0384
Mailing Address - Street 1:2124 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-2204
Mailing Address - Country:US
Mailing Address - Phone:205-279-8981
Mailing Address - Fax:
Practice Address - Street 1:4201 NORTHVIEW DR
Practice Address - Street 2:SUITE 501
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-2604
Practice Address - Country:US
Practice Address - Phone:410-220-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0714704Medicaid