Healthcare Provider Details

I. General information

NPI: 1093482705
Provider Name (Legal Business Name): MEDCITY FAMILY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 WASHINGTON BLVD
BALTIMORE MD
21230-1406
US

IV. Provider business mailing address

2509 WASHINGTON BLVD
BALTIMORE MD
21230-1406
US

V. Phone/Fax

Practice location:
  • Phone: 443-565-2408
  • Fax:
Mailing address:
  • Phone: 443-835-4228
  • Fax: 301-369-8694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: FAITH OLUBUKOLA ADEBULE
Title or Position: CEO
Credential:
Phone: 443-623-3592