Provider Demographics
NPI:1265662795
Name:KOFI SHAW-TAYLOR MD PA WESTSIDE MEDICAL GROUP
Entity Type:Organization
Organization Name:KOFI SHAW-TAYLOR MD PA WESTSIDE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KOFI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW-TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-922-7382
Mailing Address - Street 1:801 KEY HIGHWAY
Mailing Address - Street 2:STE 211 BLDG 1
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230
Mailing Address - Country:US
Mailing Address - Phone:410-922-7382
Mailing Address - Fax:410-922-7384
Practice Address - Street 1:2600 LIBERTY HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-7804
Practice Address - Country:US
Practice Address - Phone:410-922-7382
Practice Address - Fax:410-922-7384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty