Healthcare Provider Details

I. General information

NPI: 1659691681
Provider Name (Legal Business Name): IJB HEALTHCARE SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4780A ASHFORD DUNWOODY RD SUITE 621
ATLANTA GA
30338-5504
US

IV. Provider business mailing address

4780A ASHFORD DUNWOODY RD SUITE 621
ATLANTA GA
30338-5504
US

V. Phone/Fax

Practice location:
  • Phone: 770-331-8035
  • Fax: 770-458-1596
Mailing address:
  • Phone: 770-331-8035
  • Fax: 770-458-1596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number059300
License Number StateGA

VIII. Authorized Official

Name: DR. OLUGBEMIGA A. OSOBA
Title or Position: OWNER
Credential: M.D.
Phone: 770-331-8035