Provider Demographics
NPI:1548636269
Name:SAMBA, BASIRU
Entity type:Individual
Prefix:
First Name:BASIRU
Middle Name:
Last Name:SAMBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 WILLES VISION DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4671
Mailing Address - Country:US
Mailing Address - Phone:301-284-0636
Mailing Address - Fax:301-542-0184
Practice Address - Street 1:4802 WILLES VISION DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4671
Practice Address - Country:US
Practice Address - Phone:301-284-0636
Practice Address - Fax:301-542-0184
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR159377163W00000X
MDR155931163WA2000X
MDLP34564164W00000X
171M00000X, 174400000X, 246Y00000X, 247200000X, 372500000X, 372600000X, 3747A0650X, 374U00000X, 376G00000X, 376J00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No174400000XOther Service ProvidersSpecialist
No246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No376G00000XNursing Service Related ProvidersNursing Home Administrator
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide