Provider Demographics
NPI:1396986873
Name:FAIRWOOD INTERNAL MEDICINE
Entity type:Organization
Organization Name:FAIRWOOD INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OKEOWO
Authorized Official - Middle Name:DARCY
Authorized Official - Last Name:IBITOYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-245-4414
Mailing Address - Street 1:12200 ANNAPOLIS RD
Mailing Address - Street 2:SUITE 232
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9180
Mailing Address - Country:US
Mailing Address - Phone:240-245-4414
Mailing Address - Fax:240-245-4409
Practice Address - Street 1:12200 ANNAPOLIS RD
Practice Address - Street 2:SUITE 232
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9180
Practice Address - Country:US
Practice Address - Phone:240-245-4414
Practice Address - Fax:240-245-4409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051437207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD723540200Medicaid
MDP366OtherCAREFIRST FEP
MDDX1GODOtherCAREFIRST MARYLAND
MD146222Medicare PIN