Provider Demographics
NPI:1558173559
Name:BLOSSOMING MINDS PEDIATRICS
Entity type:Organization
Organization Name:BLOSSOMING MINDS PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEYVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAFEI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-506-0739
Mailing Address - Street 1:11540 CHAPEL RISE
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1464
Mailing Address - Country:US
Mailing Address - Phone:240-506-0739
Mailing Address - Fax:410-378-8327
Practice Address - Street 1:13994 BALTIMORE AVE STE 101
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5174
Practice Address - Country:US
Practice Address - Phone:410-656-4775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLOSSOMING MINDS PEDIATRICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-01-25
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty