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General NPI Number Information
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NPI Number | 1629016027
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Entity Type | Organization
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Legal Business Name | WESTSIDE MEDICAL GROUP INC
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Dates
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Enumeration Date | 06/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2600 LIBERTY HEIGHTS AVE 1ST FLOOR
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City | BALTIMORE
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State | MD
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Zip | 21215-7804
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Country | US
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Telephone | 410-383-4424
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Fax | 410-383-7918
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Provider Business Mailing Address
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Address Line | PO BOX 922
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City | BROOKLANDVILLE
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State | MD
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Zip | 21022-0922
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Country | US
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Telephone | 410-383-4424
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Fax | 410-383-7918
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Authorized Official
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Title or Position | CEO
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Name | TAJUDEEN OHIOKPEHAI
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Credential | M.D.
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Telephone | 410-383-4424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | D30115
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License Number State | MD
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