MEDICARE: DR. OLAJIDE A. BALOGUN M.D.

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	208000000X	Pediatrics Physician	20381	SC
2	207R00000X	Internal Medicine Physician	20381	SC

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

General Provider Information

NPI Number	:	1215997820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLAJIDE A. BALOGUN M.D.

Provider Business Mailing Address
First Line	:	1165 HIGHWAY 1 S
Second Line	:	SUITE 200
City	:	LUGOFF
State	:	SC
Zip	:	29078-8966
Country	:	US
Telephone Number	:	803-408-0225
Fax Number	:	803-408-0729

Provider Business Practice Location Address
First Line	:	1165 HIGHWAY 1 S
Second Line	:	SUITE 200
City	:	LUGOFF
State	:	SC
Zip	:	29078-8966
Country	:	US
Telephone Number	:	803-408-0225
Fax Number	:	803-408-0729

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

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	12/13/2007

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Directions to “ DR. OLAJIDE A. BALOGUN M.D.” Practice Location

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