Provider Demographics
NPI:1538566856
Name:BOSPHORUS PEDIATRIC, LLC
Entity type:Organization
Organization Name:BOSPHORUS PEDIATRIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER-PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMET
Authorized Official - Middle Name:
Authorized Official - Last Name:AYBAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-837-7600
Mailing Address - Street 1:130 LUBRANO DR STE 112
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7192
Mailing Address - Country:US
Mailing Address - Phone:443-837-7600
Mailing Address - Fax:443-837-7688
Practice Address - Street 1:130 LUBRANO DR STE 112
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7192
Practice Address - Country:US
Practice Address - Phone:443-837-7600
Practice Address - Fax:443-837-7688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0048164174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD692310100Medicaid
MDH48453Medicare UPIN