Healthcare Provider Details

I. General information

NPI: 1346588134
Provider Name (Legal Business Name): OBASEKI INDIANA FAMILY HEALTH CLINIC, PROF. CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 CANAL ST
EVANSVILLE IN
47713-2441
US

IV. Provider business mailing address

645 CANAL ST
EVANSVILLE IN
47713-2441
US

V. Phone/Fax

Practice location:
  • Phone: 812-491-8765
  • Fax: 812-491-8766
Mailing address:
  • Phone: 812-491-8765
  • Fax: 812-491-8766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01039780A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number71000903A
License Number StateIN

VIII. Authorized Official

Name: ART O OBASEKI
Title or Position: PRESIDENT
Credential: NP
Phone: 812-491-8765