=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528783404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGATE INTEGRATED AND BEHAVIORAL HEALTHCARE SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2022
-----------------------------------------------------
Last Update Date | 02/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3216 GREENMOUNT AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218-3438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-515-4868
-----------------------------------------------------
Fax | 443-885-9840
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3216 GREENMOUNT AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218-3438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-515-4868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. JIMOH A ADEBAYO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-515-4868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------