Healthcare Provider Details

I. General information

NPI: 1073599767
Provider Name (Legal Business Name): ERHIME T BADEJO M.D MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERHIME TEKA OGHRE-IKANONE M.D. MSN

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 10/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W JACKSON ST STE 200 CARBONDALE FAMILY MEDICINE
CARBONDALE IL
62901-1474
US

IV. Provider business mailing address

305 W JACKSON ST STE 200 CARBONDALE FAMILY MEDICINE
CARBONDALE IL
62901-1474
US

V. Phone/Fax

Practice location:
  • Phone: 618-536-6621
  • Fax: 618-453-1102
Mailing address:
  • Phone: 618-536-6621
  • Fax: 618-453-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2004020321
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2004020321
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125067577
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number125067577
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: