Healthcare Provider Details

I. General information

NPI: 1528575248
Provider Name (Legal Business Name): OSWARLD NIYIDUHA IRAKUNDA RUSIBAMAYILA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W NORTHMOOR RD
PEORIA IL
61614-3435
US

IV. Provider business mailing address

7345 WOODLAND DR STE D
INDIANAPOLIS IN
46278-1737
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-2200
  • Fax:
Mailing address:
  • Phone: 317-286-2885
  • Fax: 317-536-3097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number893242
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN273461
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041405733
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: