=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205324225
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIN-OBGYN OF MARYLAND PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2018
-----------------------------------------------------
Last Update Date | 04/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10401 HOSPITAL DRIVE SUITE 103
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-856-0334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10401 HOSPITAL DR STE 103
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20735-3150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/MD
-----------------------------------------------------
Name | DR. EBENEZER NETTEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 301-856-0334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------