MEDICARE: FIDELIA O OSINUBI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	001305	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	06/11/1956	OTHER	GA	BIRTH DATE

General Provider Information

NPI Number	:	1013194661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FIDELIA O OSINUBI MD

Provider Business Mailing Address
First Line	:	P.O. BOX 20156
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30325
Country	:	US
Telephone Number	:	404-349-0496
Fax Number	:	404-349-6081

Provider Business Practice Location Address
First Line	:	3885 PRINCETON LAKES WAY
Second Line	:	SUITE 402
City	:	ATLANTA
State	:	GA
Zip	:	30331-5599
Country	:	US
Telephone Number	:	404-349-0496
Fax Number	:	404-349-6081

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2008
Last Update Date	:	11/01/2012

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