Healthcare Provider Details

I. General information

NPI: 1255780342
Provider Name (Legal Business Name): OLUMIDE AYODEJI FANIYAN MBBS, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST DEPARTMENT OF PEDIATRICS, ADMINISTRATION BUILDING #1134
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1901 W HARRISON ST DEPARTMENT OF PEDIATRICS, ADMINISTRATION BUILDING #1134
CHICAGO IL
60612-3714
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-4505
  • Fax:
Mailing address:
  • Phone: 312-864-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125069281
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: