Provider Demographics
NPI:1992073084
Name:BENJAMIN A. ADEWALE MD PC
Entity type:Organization
Organization Name:BENJAMIN A. ADEWALE MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEWALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-569-8028
Mailing Address - Street 1:25 S QUAKER LN
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4585
Mailing Address - Country:US
Mailing Address - Phone:571-257-4398
Mailing Address - Fax:703-823-4407
Practice Address - Street 1:25 S QUAKER LN
Practice Address - Street 2:SUITE 4
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4585
Practice Address - Country:US
Practice Address - Phone:571-257-4398
Practice Address - Fax:703-823-4407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD22004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC031768500Medicaid