Provider Demographics
NPI:1730293416
Name:OBGYN AFFILIATES, PA
Entity Type:Organization
Organization Name:OBGYN AFFILIATES, PA
Other - Org Name:OBGYN AFFILIATES IMAD S MUFARRIJ, MANJIT RISAM
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:IMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MUFARRIJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-249-4090
Mailing Address - Street 1:3060 MITCHELLVILLE RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716
Mailing Address - Country:US
Mailing Address - Phone:301-249-4090
Mailing Address - Fax:301-390-1344
Practice Address - Street 1:3060 MITCHELLVILLE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716
Practice Address - Country:US
Practice Address - Phone:301-249-4090
Practice Address - Fax:301-390-1344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0032735174400000X
MDD0031265174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD528351500Medicaid
MD41836101OtherBLUE CROSS BLUE SHIELD
MD41836101OtherBLUE CROSS BLUE SHIELD