=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407662901
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT HEALTH MEDICAL GROUP MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2024
-----------------------------------------------------
Last Update Date | 06/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 BRIGHTFIELD RD
-----------------------------------------------------
City | LUTHERVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-3643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-470-0288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 407 WILLOUGHBY AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11205-4590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AZLAN TARIQ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-709-7238
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------