Healthcare Provider Details

I. General information

NPI: 1669865374
Provider Name (Legal Business Name): EMMANUEL OGELE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E HURON ST SUITE 1 - 200
CHICAGO IL
60611-2909
US

IV. Provider business mailing address

446 W ARLINGTON PL 3
CHICAGO IL
60614-7374
US

V. Phone/Fax

Practice location:
  • Phone: 312-503-7975
  • Fax:
Mailing address:
  • Phone: 831-402-7867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01086240A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: