Healthcare Provider Details

I. General information

NPI: 1689849895
Provider Name (Legal Business Name): DR. SAMIR BHASIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SAMIR BHASIN DO

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 OAK MANOR DR SUITE 203
GLEN BURNIE MD
21061-5548
US

IV. Provider business mailing address

331 OAK MANOR DR SUITE 203
GLEN BURNIE MD
21061-5548
US

V. Phone/Fax

Practice location:
  • Phone: 410-768-0700
  • Fax: 410-768-1143
Mailing address:
  • Phone: 410-768-0700
  • Fax: 410-768-1143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number148994
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH72041
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: