Provider Demographics
NPI:1821015264
Name:BENJAMIN ADEWALE MD PC
Entity Type:Organization
Organization Name:BENJAMIN ADEWALE MD PC
Other - Org Name:RIVERSIDE MENTAL HEALTH LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR MD
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:ADYSON
Authorized Official - Last Name:ADENWALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-569-8028
Mailing Address - Street 1:PO BOX 8057
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-8057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7011 CALAMO ST
Practice Address - Street 2:#105
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150
Practice Address - Country:US
Practice Address - Phone:703-569-8028
Practice Address - Fax:703-569-8085
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENJAMIN A. ADEWALE MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-15
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084N0400X, 2084P0800X, 363L00000X
VA0101054165261QV0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVAGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
490745Medicare ID - Type UnspecifiedJOHNSON
491533Medicare ID - Type UnspecifiedOKOTO
877428Medicare ID - Type UnspecifiedADEWALE