Provider Demographics
NPI:1174625057
Name:BETHEL MEDICAL CLINIC CHARTERED
Entity type:Organization
Organization Name:BETHEL MEDICAL CLINIC CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BABAJIDE
Authorized Official - Middle Name:AYODEJI
Authorized Official - Last Name:OBADINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:301-345-3966
Mailing Address - Street 1:7325 HANOVER PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3618
Mailing Address - Country:US
Mailing Address - Phone:301-345-3966
Mailing Address - Fax:301-982-2937
Practice Address - Street 1:7325 HANOVER PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3618
Practice Address - Country:US
Practice Address - Phone:301-345-3966
Practice Address - Fax:301-982-2937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD127041900Medicaid
MDKP71BEOtherCAREFIRST BCBS GROUP #
DCC500OtherCAREFIRSTBCBS DC GROUP #
MDKP71BEOtherCAREFIRST BCBS GROUP #