1417944091 NPI number — OSARETIN B IDUSUYI MD

Table of content: OSARETIN B IDUSUYI MD (NPI 1417944091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417944091 NPI number — OSARETIN B IDUSUYI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IDUSUYI
Provider First Name:
OSARETIN
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417944091
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1118 HAMPSHIRE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62301-3027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-222-6550
Provider Business Mailing Address Fax Number:
217-277-2253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1118 HAMPSHIRE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62301-3027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-222-6550
Provider Business Practice Location Address Fax Number:
217-277-2253
Provider Enumeration Date:
09/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  036095609 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0004X , with the licence number: 036095609 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036095609 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com