Provider Demographics
NPI:1700364445
Name:EDUNG, TOM BASSEY
Entity Type:Individual
Prefix:MRS
First Name:TOM
Middle Name:BASSEY
Last Name:EDUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 STEMMERS RUN RD STE I
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21221-3361
Mailing Address - Country:US
Mailing Address - Phone:443-453-2069
Mailing Address - Fax:443-559-5645
Practice Address - Street 1:617 STEMMERS RUN RD STE I
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-3361
Practice Address - Country:US
Practice Address - Phone:443-453-2069
Practice Address - Fax:443-559-5645
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR4294251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD82-5242842Medicaid