Healthcare Provider Details

I. General information

NPI: 1568729333
Provider Name (Legal Business Name): OSAYAME AUSTINE EKHAGUERE MB, BS, MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5165 MCCARTY LN
LAFAYETTE IN
47905-8764
US

IV. Provider business mailing address

PO BOX 778912
CHICAGO IL
60677-8912
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-838-4758
Mailing address:
  • Phone: 317-777-6435
  • Fax: 317-777-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01079516A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01079516A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: