Provider Demographics
NPI:1386452803
Name:EDWARD BANISOBA, SAMGELLA SR
Entity type:Individual
Prefix:MR
First Name:SAMGELLA
Middle Name:
Last Name:EDWARD BANISOBA
Suffix:SR
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 1:1771 ELTON RD # 1771
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-1757
Mailing Address - Country:US
Mailing Address - Phone:240-267-3748
Mailing Address - Fax:
Practice Address - Street 1:4512 DOCTOR BEANS LEGACY CIR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-6384
Practice Address - Country:US
Practice Address - Phone:240-267-3748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator