Healthcare Provider Details

I. General information

NPI: 1699105395
Provider Name (Legal Business Name): BALI HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 BRIGHTSEAT RD
LANDOVER MD
20785-4250
US

IV. Provider business mailing address

PO BOX 6854
LARGO MD
20792-6854
US

V. Phone/Fax

Practice location:
  • Phone: 301-364-3300
  • Fax: 301-364-3305
Mailing address:
  • Phone: 301-364-3300
  • Fax: 301-364-3305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0052015
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0052015
License Number StateMD

VIII. Authorized Official

Name: ALFRED SIBEDWO
Title or Position: PRESIDENT/CEO
Credential:
Phone: 301-364-3300