MEDICARE: EROMONSELE O. IDAHOSA 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	174400000X	Specialist	01057350A	IN
2	207P00000X	Emergency Medicine Physician	01057350A	IN
3	207R00000X	Internal Medicine Physician	01057350A	IN

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	:	1588659924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EROMONSELE O. IDAHOSA MD

Provider Business Mailing Address
First Line	:	8354 LITTLE EAGLE COURT
Second Line	:	SUITE C
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46234
Country	:	US
Telephone Number	:	317-291-1211
Fax Number	:	317-291-1194

Provider Business Practice Location Address
First Line	:	8354 LITTLE EAGLE COURT
Second Line	:	SUITE C
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46234
Country	:	US
Telephone Number	:	317-291-1211
Fax Number	:	317-291-1194

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

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	10/06/2011

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