Provider Demographics
NPI:1396860284
Name:OPTIMUM HEALTH SYSTEMS, INC.
Entity Type:Organization
Organization Name:OPTIMUM HEALTH SYSTEMS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMSON
Authorized Official - Middle Name:
Authorized Official - Last Name:OMOTOSHO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, RN, C
Authorized Official - Phone:443-858-3189
Mailing Address - Street 1:3709 COLLIER RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-3401
Mailing Address - Country:US
Mailing Address - Phone:443-858-3189
Mailing Address - Fax:410-233-6201
Practice Address - Street 1:2300 GARRISON BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2335
Practice Address - Country:US
Practice Address - Phone:410-233-6200
Practice Address - Fax:410-233-6201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD07661762261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402529600Medicaid
MD404189100Medicaid
MD241NMedicare ID - Type UnspecifiedPROVIDER NUMBER