Provider Demographics
NPI:1508130618
Name:AGEWELL ALLIANCE
Entity Type:Organization
Organization Name:AGEWELL ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEBIMPE
Authorized Official - Middle Name:
Authorized Official - Last Name:OBADARE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:443-520-0563
Mailing Address - Street 1:9520 BERGER RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9520 BERGER RD
Practice Address - Street 2:SUITE 212
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1501
Practice Address - Country:US
Practice Address - Phone:443-520-0563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty