Provider Demographics
NPI:1861849051
Name:YOUR TIME MEDICAL, PC
Entity Type:Organization
Organization Name:YOUR TIME MEDICAL, PC
Other - Org Name:OT FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:IMMIRNE
Authorized Official - Middle Name:MONET
Authorized Official - Last Name:OUWINGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-791-2223
Mailing Address - Street 1:3307 FERRY LANDING RD
Mailing Address - Street 2:
Mailing Address - City:DUNKIRK
Mailing Address - State:MD
Mailing Address - Zip Code:20754-9647
Mailing Address - Country:US
Mailing Address - Phone:718-791-2223
Mailing Address - Fax:
Practice Address - Street 1:10339 SOUTHERN MARYLAND BLVD STE 206
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:MD
Practice Address - Zip Code:20754-3018
Practice Address - Country:US
Practice Address - Phone:443-646-3532
Practice Address - Fax:404-480-3984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0078131207Q00000X
2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD424573300Medicaid