Healthcare Provider Details

I. General information

NPI: 1710930011
Provider Name (Legal Business Name): FATAI BOLAJI ADISA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8691 CONNECTICUT ST STE C
MERRILLVILLE IN
46410-5541
US

IV. Provider business mailing address

PO BOX 10644
MERRILLVILLE IN
46411-0644
US

V. Phone/Fax

Practice location:
  • Phone: 219-525-4176
  • Fax: 219-472-0841
Mailing address:
  • Phone: 219-525-4176
  • Fax: 219-750-9451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05005905A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: