Provider Demographics
NPI:1043791122
Name:DEBOBETH MEDICAL CENTER
Entity type:Organization
Organization Name:DEBOBETH MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MERCY
Authorized Official - Middle Name:
Authorized Official - Last Name:FADOJU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-904-5129
Mailing Address - Street 1:2144 CHANTILLA RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-3703
Mailing Address - Country:US
Mailing Address - Phone:443-904-5129
Mailing Address - Fax:
Practice Address - Street 1:3107 ERDMAN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1719
Practice Address - Country:US
Practice Address - Phone:443-904-5129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDW18743245261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD168716600Medicaid