Healthcare Provider Details

I. General information

NPI: 1265662795
Provider Name (Legal Business Name): KOFI SHAW-TAYLOR MD PA WESTSIDE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 10/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 LIBERTY HEIGHTS AVE
BALTIMORE MD
21215-7804
US

IV. Provider business mailing address

801 KEY HIGHWAY STE 211 BLDG 1
BALTIMORE MD
21230
US

V. Phone/Fax

Practice location:
  • Phone: 410-922-7382
  • Fax: 410-922-7384
Mailing address:
  • Phone: 410-922-7382
  • Fax: 410-922-7384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KOFI SHAW-TAYLOR
Title or Position: OWNER
Credential: MD
Phone: 410-922-7382