Healthcare Provider Details

I. General information

NPI: 1255695136
Provider Name (Legal Business Name): IBRAHIM ATSEJUWAWE USMAN-OYOWE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

1800 LOMBARD ST GROUND FLR
PHILADELPHIA PA
19146
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax:
Mailing address:
  • Phone: 215-662-3259
  • Fax: 215-615-3610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125061518
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD456524
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: