Provider Demographics
NPI:1568559714
Name:LAND MEDICAL, INC.
Entity type:Organization
Organization Name:LAND MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:I
Authorized Official - Last Name:BALOGUN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:267-993-0256
Mailing Address - Street 1:4 NESHAMINY INTERPLEX DR STE 101
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-6940
Mailing Address - Country:US
Mailing Address - Phone:215-294-6790
Mailing Address - Fax:
Practice Address - Street 1:4 NESHAMINY INTERPLEX DR STE 101
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6940
Practice Address - Country:US
Practice Address - Phone:215-294-6790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101200261Q00000X
261Q00000X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018467050006Medicaid
PA0018467050006Medicaid
PA088923Medicare UPIN
PA0018467050006Medicaid