Healthcare Provider Details

I. General information

NPI: 1265295125
Provider Name (Legal Business Name): GENESIS HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8509 GLEN MICHAEL LN APT T3
RANDALLSTOWN MD
21133-5227
US

IV. Provider business mailing address

127 PITTSTON CIR
OWINGS MILLS MD
21117-1723
US

V. Phone/Fax

Practice location:
  • Phone: 410-258-0565
  • Fax:
Mailing address:
  • Phone: 410-258-0565
  • Fax: 410-237-6306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. BOLAJI OLUGBOJA
Title or Position: MEDICAL DIRECTOR
Credential: DNP PMHNP
Phone: 410-258-0565