Provider Demographics
NPI:1407045743
Name:IMANOEL ENTERPRISE, INC
Entity Type:Organization
Organization Name:IMANOEL ENTERPRISE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:BABAK
Authorized Official - Middle Name:
Authorized Official - Last Name:IMANOEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:410-751-5830
Mailing Address - Street 1:9115 FIELD RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-1003
Mailing Address - Country:US
Mailing Address - Phone:410-751-5830
Mailing Address - Fax:
Practice Address - Street 1:218 WASHINGTON HEIGHTS MED CTR
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5633
Practice Address - Country:US
Practice Address - Phone:410-751-5830
Practice Address - Fax:410-751-7450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH53939207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H11320Medicare UPIN
901MMedicare PIN