Healthcare Provider Details

I. General information

NPI: 1073755021
Provider Name (Legal Business Name): AFIZ A. TAIWO, MD. MPH. S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 04/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 PINEHURST DR
PALOS HEIGHTS IL
60463-2911
US

IV. Provider business mailing address

PO BOX 449
PALOS HEIGHTS IL
60463-0449
US

V. Phone/Fax

Practice location:
  • Phone: 708-334-9494
  • Fax:
Mailing address:
  • Phone: 708-334-9494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number042617704
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number042617704
License Number StateIL

VIII. Authorized Official

Name: DR. AFIZ ADEWALE TAIWO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 708-334-9494