Healthcare Provider Details

I. General information

NPI: 1366040065
Provider Name (Legal Business Name): ADEBISI MARY FAGBOHUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 REID PKWY
RICHMOND IN
47374-1157
US

IV. Provider business mailing address

1100 REID PKWY MEDICAL STAFF SERVICES
RICHMOND IN
47374-1157
US

V. Phone/Fax

Practice location:
  • Phone: 765-983-3000
  • Fax:
Mailing address:
  • Phone: 765-935-8808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01091276A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: