Provider Demographics
NPI:1710618152
Name:MEDHAVEN HEALTH LLC
Entity Type:Organization
Organization Name:MEDHAVEN HEALTH LLC
Other - Org Name:MEDHAVEN LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRNP
Authorized Official - Prefix:
Authorized Official - First Name:OLUWAKEMI
Authorized Official - Middle Name:F
Authorized Official - Last Name:BALOGUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-515-6550
Mailing Address - Street 1:7310 RITCHIE HWY STE 519
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3099
Mailing Address - Country:US
Mailing Address - Phone:240-515-6550
Mailing Address - Fax:
Practice Address - Street 1:7310 RITCHIE HWY STE 519
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3099
Practice Address - Country:US
Practice Address - Phone:240-515-6550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1962963389Medicaid