Healthcare Provider Details

I. General information

NPI: 1992029987
Provider Name (Legal Business Name): HENRY M OGBUAGU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

IV. Provider business mailing address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5360
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-6220
  • Fax:
Mailing address:
  • Phone: 618-257-6220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number90333
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036164945
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number90333
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036164945
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: