Provider Demographics
NPI:1558879189
Name:MBAH, COLLINS M
Entity Type:Individual
Prefix:
First Name:COLLINS
Middle Name:M
Last Name:MBAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 16TH AVE APT T3
Mailing Address - Street 2:
Mailing Address - City:CHILLUM
Mailing Address - State:MD
Mailing Address - Zip Code:20782-3410
Mailing Address - Country:US
Mailing Address - Phone:301-529-6442
Mailing Address - Fax:
Practice Address - Street 1:5415 16TH AVE APT T3
Practice Address - Street 2:
Practice Address - City:CHILLUM
Practice Address - State:MD
Practice Address - Zip Code:20782-3410
Practice Address - Country:US
Practice Address - Phone:301-529-6442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13410374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide