MEDICARE: MARY ABIMBOLA ADERINKOMI

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	164W00000X	Licensed Practical Nurse	L043096-8	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	106502	OTHER	MN	UCARE MN
2	4J19CA	OTHER	MN	BCBS
3	181585	OTHER	MN	UCARE MN PCA
4	37865	OTHER	MN	HEALTH PARTNERS
5	5900010	OTHER	MN	MEDICA

General Provider Information

NPI Number	:	1639207723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ABIMBOLA ADERINKOMI

Provider Business Mailing Address
First Line	:	10781 REGENT AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55443-5003
Country	:	US
Telephone Number	:	651-659-0208
Fax Number	:	651-659-0161

Provider Business Practice Location Address
First Line	:	1953 UNIVERSITY AVE W
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-3427
Country	:	US
Telephone Number	:	651-659-0208
Fax Number	:	651-659-0161

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/09/2007

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