Healthcare Provider Details

I. General information

NPI: 1902268352
Provider Name (Legal Business Name): MR. FAMOUS IWINOSA OSASUYI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11555 AUTUMN TERRACE DR
WHITE MARSH MD
21162-1152
US

IV. Provider business mailing address

11555 AUTUMN TERRACE DR
WHITE MARSH MD
21162-1152
US

V. Phone/Fax

Practice location:
  • Phone: 443-226-6339
  • Fax: 443-919-0209
Mailing address:
  • Phone: 443-226-6339
  • Fax: 443-919-0209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: