Provider Demographics
NPI:1558635235
Name:MARYLAND CHILDREN HEALTH CENTER
Entity Type:Organization
Organization Name:MARYLAND CHILDREN HEALTH CENTER
Other - Org Name:MARY OGUNSANYA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNSANYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-218-0398
Mailing Address - Street 1:P.O.BOX 2132
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20718-2132
Mailing Address - Country:US
Mailing Address - Phone:301-218-0398
Mailing Address - Fax:301-218-0040
Practice Address - Street 1:12150 ANNAPOLIS RD
Practice Address - Street 2:STE 208
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9183
Practice Address - Country:US
Practice Address - Phone:301-218-0398
Practice Address - Fax:301-218-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD005630261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care