Healthcare Provider Details

I. General information

NPI: 1295270239
Provider Name (Legal Business Name): OLUSEUGUN OGUNGBEMI M.D/CEO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2016
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7645 N SHERIDAN RD
CHICAGO IL
60626-1345
US

IV. Provider business mailing address

7645 N SHERIDAN RD
CHICAGO IL
60626-1345
US

V. Phone/Fax

Practice location:
  • Phone: 773-817-5608
  • Fax:
Mailing address:
  • Phone: 773-817-5608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: