Healthcare Provider Details

I. General information

NPI: 1215093786
Provider Name (Legal Business Name): BAYSIDE BEHAVIORAL HEALTH CLINIC OF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2444 SOLOMONS ISLAND RD STE 205
ANNAPOLIS MD
21401-3723
US

IV. Provider business mailing address

PO BOX 6250
ELLICOTT CITY MD
21042-0250
US

V. Phone/Fax

Practice location:
  • Phone: 410-292-4559
  • Fax:
Mailing address:
  • Phone: 410-292-4559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ADELEKE A OGUNMEFUN
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 410-292-4559