Healthcare Provider Details

I. General information

NPI: 1952996787
Provider Name (Legal Business Name): MR. MICHAEL OSAGEDE IMOMOH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E UNIVERSITY PKWY
BALTIMORE MD
21218-2829
US

IV. Provider business mailing address

13219 EXECUTIVE PARK TER
GERMANTOWN MD
20874-2647
US

V. Phone/Fax

Practice location:
  • Phone: 410-554-2626
  • Fax:
Mailing address:
  • Phone: 240-898-5075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR219198
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: