Provider Demographics
NPI:1588962245
Name:GENNESARET MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:GENNESARET MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TOYIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OPESANMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-963-5870
Mailing Address - Street 1:12108 EARLY LILACS PATH
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1676
Mailing Address - Country:US
Mailing Address - Phone:410-963-5870
Mailing Address - Fax:410-528-6004
Practice Address - Street 1:13992 BALTIMORE AVE STE 200
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5010
Practice Address - Country:US
Practice Address - Phone:410-528-6003
Practice Address - Fax:410-528-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-04
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059876261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000911300Medicaid
MD000911300Medicaid